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conflict de-escalation and motivational interviewing, problem-solving skills and education about trauma-informed care, and peer engagement, leadership, and empowerment.
Each employee applicant is required to complete volunteer and employment paperwork, obtain a CA ID, Social Security card, phone, and bank account for direct deposit, and demonstrate eligibility to work. They are assisted in this process by the Director, Field Supervisor, and SOS volunteers. Interns and employees are supported to secure transportation and conduct legal vehicle registration and operation. Each applicant will be assisted with developing a professional resume.
Streets Team members are expected to be the models for others, not only in their work performance but also in their personal living arrangements and relationships. Interns and employees are continually encouraged and supported to make personal improvements in their lives to obtain more stable dwellings and living conditions, and improve their personal health, emotional stability, and overall satisfaction and wellbeing.
Employees are prioritized to participate in the interim sheltering opportunities as they are developed by SOS! Richmond and the City. Each employee is expected to benefit from obtaining permanent housing and the means to sustain it with employment and an active “personal program” that keeps people working on their personal health.
Workforce development focuses on practicing teamwork according to a daily communication system and clear performance standards that are modeled by the Field Supervisor. Employees demonstrate their accessibility and dependability. They learn to model a positive outlook and the motivation for improving neighborhood quality-of-life and encampment living conditions. They are supportive of their peers to help them be healthy and engaged in Safety Guardian activities. Each Streets Team member recommends new volunteers to become Streets Team members. As an employee begins to excel in job performance, the hours increase and become more regular, responsibilities are nuanced and shaped to that individual’s aptitudes and strengths, and the employee advances in hourly and then salaried pay rates.
Local engagement focuses on safety, problem-solving and personal welfare to improve public safety. One of the most pressing issues at unsupported and managed encampments is the need for improved security to support public safety. It has thus far been difficult to implement successful security measures, even at managed encampments. The Streets Team will engage local stewards to work during late afternoons and evening hours to target three activities: trash collection, problem-solving, and advocating for people’s welfare. These activities together will bring more attention
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and care to situations that otherwise might result in problems with safety. Such activities may increase self-management practices among encampment dwellers.
The Streets Team is composed of local stewards and a mobile team. A local steward will be present at larger encampment locations to provide for “traditional” Streets Team activities such as trash cleanup. An additional task for select employees will involve talking with individuals to focus on welfare checks. By casually offering to support people’s needs, staff will seek to address what is not working and problem-solve in the moment or at the earliest next opportunity. With clipboard in-hand and by asking one or two simple questions, the Streets Team can respond to people’s expressed needs. In response, the Streets Team’s mobile team, Area Director, SOS volunteers, and program partners, including Housing Consortium of the Easy Bay (HCEB), will be responsive to these needs. The local steward will also lead in the empowerment of unsheltered residents to steward their locations to improve personal and public health, safety, and neighborhood order. Improving safety and security will thus involve proactive steps that can be taken by working with the residents who are receptive to support and are willing to participate.
Individually focused engagement will lead to community development at locations where people lack access to caring, trusted, and sustained relationships. The activity of securing and managing shared public spaces will lead to safer, more organized environments which will improve conditions and relationships in neighborhoods impacted by homelessness. The health and safety-focused engagement and empowerment activities will help to provide stewardship that supports the security of public spaces.
Mobile team to act as assertive community liaisons and problem solvers at problematic neighborhood locations. The mobile team will operate two shifts during the day and into the night to provide responses to neighborhood complaints or concerns related to homelessness and address these in a sustained and proactive manner. The team’s expansion of its capacity as assertive community liaison will improve neighborhood quality of life with its presence at problematic encampment and curbside locations and increase civility at public spaces. The mobile team will function as field supervision for the local stewards and Streets Team members as they work in the field. They will also provide observation and responses for the Secure Scattered Sites to ensure that host properties and the households residing on-site are safe and acting in accordance with contractual agreements.
The mobile team fulfills a basic function of picking up trash bags and debris that is dumped at specified locations. As the mobile team travels across Richmond and fulfills
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the Streets Team’s work at specific locations according to a predictable schedule, the team will also be responsive to requests for support from local guardians, concerned neighbors, public agencies, including CORE’s mobile outreach (CORE ceases its work at 4PM), and other public and private groups and institutions that express their neighborhood’s needs.
The team will answer these basic needs at encampments, streets, and other locations where unhoused individuals otherwise lack support, especially in the evenings when problems most often arise. It will regularly check in on individuals, especially vulnerable ones, and will keep track of where they are, how their needs are being met, and assist them in obtaining support and access to services in collaboration with program partners and mainstream providers. The mobile team will pass out bags, collect filled bags, and use their clipboards to keep track of promises for support.
The mobile team will provide a presence to deter illegal dumping and provide prompt responses when these calls are dispatched. It will also practice a light touch to address those concerns of quality-of-life and civility that can be safety responded to and which may mitigate public agency responses.
When practicable and safe, the mobile team can respond to concerns related to homelessness during evenings and nights until 3AM. It is during these late hours when a presence might make the difference in preventing crime and disorderly behaviors, especially at locations where local stewards request support and supervision by the mobile team for problem-solving.
The mobile homeless engagement team will address neighborhood complaints.
Collaboration with city and county agencies will expand for assertive public safety responses, improve communication lines with neighborhood housed residents, leaders, and groups, and potentially integrate with real-time dispatch call systems.
Manage and support Safe Parking Host program locations for vehicle dwellers. Interim sheltering solutions will offer safety, stability, and a cleaner, healthier environment, as well as a pathway to permanent housing. As tent and vehicle-dwelling households are disbursed from encampment locations, SOS Richmond will recruit the support of public and private property owners (churches, nonprofits and eventually businesses) to temporarily utilize vacant lots and parking lots to provide stable and secure transitions for select households. Secure sites are contracted for one to four households with private hosts. In its role as liaison and resource provider, SOS Richmond facilitates a successful relationship between household, host and immediate neighbors. The Streets Team will support the host and the households residing at each scattered site, manage
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the provision of on-site amenities, and provide centralized services that bring households to convergent resources. The mobile team will support the security of these sites in the evenings and ensure that households adhere to contractual agreements.
The Safe Parking Host program will support the provision of basic needs such as safe and stable shelter, food, water, and hygiene, as well as a sense of community, purpose, dignity, and hope. For each resident, a personalized service plan will be developed based on individual need, and focused on procurement of housing, may include medical and dental care, housing assistance, help applying for benefits and health insurance, employment counseling, job training or job placement, financial literacy counseling. The scattered site program will be for those who are not in need of mental health and substance abuse services.
Hosts will be interviewed by the SOS Director to establish what amenities are already present on the site and what types of situations they can accommodate (such as disability, children, etc.), and to gather information that will assist in selecting one or more households that are likely to be compatible with the host and the immediate surroundings. Interested vehicle dwellers will be interviewed by the SOS Field Supervisor and the Case Manager to determine their needs in terms of resources, supportive services, and the functionality of their vehicles.
Once the host's permit is approved, contractual agreements will outline the responsibilities of Host, SOS, and Guest. The Streets Team will assist the hosts with preparing their sites for the arrival of the guests. Depending on the site, this may include arranging for installation of a portable toilet and handwashing station, procurement of a drinking water storage tank, and any other assistance deemed necessary by the host.
They will assist the guests with meeting any compliance requirements related to the vehicle. The Field Supervisor will provide coaching for each household to prepare them for the responsibility and to promote accountability in their role as steward of the host's property. Once the guests have been settled at the site, a Streets Team member will visit on a regular basis to assist with any needs the guests may have, and to ensure that the arrangement is working out for both parties.
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Appendix 9. Police Accountability and Civilian Oversight
The scope of this appendix focuses on three subject areas:
1. Fair and Impartial Policing
2. Strengthening the Police Accountability Board
3. Saturation policing versus evidence-based constitutional policing
NICJR makes a brief mention of the PAB. Neither discuss policing strategies especially the Crime Suppression Unit, other than to affirm the move of low-risk and non-criminal matters away from the BPD sphere.
1. Fair and Impartial Policing: In February 2021, the City Council adopted the Fair and Impartial Policing platform recommended by the mayor’s working group, and referred it to the City Manager for implementation, with a consultative/oversight role given to the PAB, which came into existence on July 1, 2021.
The platform had significant overlap with the Reimagining initiative in areas such as reducing the police footprint, BerkDOT, and de-emphasizing stops for low- level, non-criminal, and especially non-safety related vehicle infractions.
Racial disparities in police stops, searches, outcomes (enforcement yield) and use of force were the impetus for the formation of the working group in 2018- 2019. This is also the area where the F&I platform made its distinctive contribution.
The core element of the platform addressing discriminatory stops is the Early Intervention System (EIS), which has been shown in neighboring cities to reduce racial disparities in police encounters.
While the BPD has a provision for an Early Warning System (EWS), the EIS will be an important departure in two ways. Firstly, it may be triggered by a statistical indication of racially disparate policing. Secondly, the goal is not only to locate, assist, and correct individual outlier officers, but to investigate, understand and address patterns and departmental problems giving rise to systemic disparities.
The program was mandated almost a year ago, and the elements of the EIS were elaborated over three years ago, in late 2017, by the Police Review Commission. The BPD has drafted an amended EWS/EIS policy but has not shared it with the PAB oversight body, the F&I working group, or members of the
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City Council, though it has shared it with the police association, which represents the officers conducting the disparate stops.
Important elements of the EIS program passed by Council include, among others:
b. Analyze data to determine whether racial disparities are generalized across the force or are concentrated in a smaller subset of outlier officers or squads/groups of officers. c. Where disparities are concentrated in an individual or a group of officers, with no race-neutral legitimate evidence for this behavior in specific cases, initiate an investigation to determine the cause for the disparity.
c. The goal of this process is to achieve trust and better community relations between the department as a whole and all the people in Berkeley. Formal discipline is a last resort unless there are violations of Department General Orders, in which case this becomes an IAB matter.
f. An outside observer from the PAB shall sit in on the risk management and/or EIS program.
The Task Force strongly recommends that the city administration take stronger steps to ensure the rapid implementation of the Council’s F&I platform.
Notwithstanding the explanations by the authorities for their delay, including the pandemic, staff vacancies, and a rise in some categories of crime, in the six plus years since BPD’s racial disparities came to light the disparities in stops remain as high as ever.
The raw numbers of Black and white civilians stopped by police are roughly equivalent and given the wide demographic disparity between the two groups, there is over a six to one disparity in a Black person’s odds of being stopped by Berkeley police compared to a white person’s, with the attendant legal, physical, psychological, and financial costs that entails. And the chances of a Black civilian who is stopped receiving no enforcement is about 25% higher than for a white civilian, indicating that many more Black people are stopped for no legitimate reason. 82
82 See charts in Fair and Impartial Working Group presentation to RIPSTF, May 19, 2021, https://www.cityofberkeley.info/uploadedFiles/Clerk/Level_3_- _Commissions/Fair%20and%20Impartial%20WG%20-%20Task%20Force.pptx-1.pdf
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Fairness and impartiality are not simply an option for the police, one among many priorities, or something they can do when they get around to it. The issue of racial disparities is clearly documented and demand immediate change. The methods to address it have been laid out. The government has mandated implementation. After years of delay, the legitimacy of the public safety system is being undermined at a cost to the whole city.
Specific recommendations:
• Bring PAB representation into the EIS planning sessions. • Clarify the plan for establishing and operating the EIS, including its use as a tool to investigate the reasons for the stubborn, systemic persistence of racial disparities in Berkeley policing.
• Set a near-term timeline for implementation.
• Report on implementation, findings, and outcomes to the PAB and the Council.
2. Police Accountability Board and Director:
The passage of Measure ii a year ago was a big step forward for police accountability. But the PAB can only succeed if it has maximum support from both city administration and City Council. The Task Force strongly recommends the following steps as examples of support for the PAB:
• The Surveillance Ordinance imposes specific responsibilities on the City Manager when acquiring new surveillance technologies, including presenting a Surveillance Use Policy for PAB review before the Council may vote to acquire, use, or pay for such technologies.83 A similar process is required by the Police Equipment and Community Safety Ordinance with regard to each Controlled Equipment Impact Report and Use Policy.84 Council should go beyond these minimum requirements to request PAB advice prior to making even a policy decision to proceed toward such acquisitions. • Council placed a provision in Measure ii stating that BPD must share General Orders with the PAB within 30 days of implementation. This was a step back from the past practice of the BPD and PRC working together to develop such policies. Yet this charter provision represents only a minimal requirement.
Council and city management should establish a higher standard of practice that emulates the past practice with the PRC.
83 Specific triggers requiring presentation of the Use Policy to the PRC, now the PAB, include seeking, soliciting, or accepting grant funds for, acquiring, using, or entering into an agreement to share or use another party’s surveillance technology. “ACQUISITION AND USE OF SURVEILLANCE TECHNOLOGY,” https://berkeley.municipal.codes/BMC/2.99.030
84 https://berkeley.municipal.codes/BMC/2.100
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The BPD and city management need to see the PAB as a partner in making policing policy. It should never be the case that the BPD says they cannot share a proposed policy with PAB because they are sharing it first with the police association.
• Measure ii gives the City Council the power to review and override the PAB regulations governing the civilian complaint review process. When PAB proposes a provision that will make it easier for people from historically marginalized communities to raise and pursue complaints of police misconduct, such a provision should carry a strong presumption of support from the Council.
3. Saturation Policing versus Constitutional or Evidence-Based Policing: Key to the proposals from the Fair and Impartial Working Group, later approved by the City Council, was this understanding of evidence-based policing:
Dr. Frank Baumgartner’s analysis reveals that “investigatory stops” (stops that use a minor infraction as a pretext for investigating rather than to prevent or reduce dangerous behavior) allow for the most officer discretion and open the possibility of implicit bias.85 Based on analyses of more than 9 million stops, Baumgartner’s team found that 47% were investigatory and that they added substantially to the racial disparity statistics. Thus, investigatory stops and stops of criminal suspects shall be restricted to those made because the person and/or vehicle fits a description in relation to a specific crime.86
Such investigatory or pretextual stops were demonstrated in the extreme by the New York PD’s massive stop-and-frisk practice that was ended by federal court order in 2013. Judge Shira Sheindlin ruled that the tactic violated the U.S.
Constitution’s Fourth Amendment’s prohibition of unreasonable searches and seizures.87
A related concern is the strategy of zero tolerance and aggressive policing, which “has been found to produce statistically insignificant changes in crime, on average. It also runs the risk of damaging police-community relations, both locally and even at the national level.”88
85 Suspect Citizens, Dr. Frank Baumgartner, 53-55 and 190-192 86 Eberhardt, J. L. (2016). Strategies for change: Research initiatives and recommendations to improve police- community relations in Oakland, Calif. Stanford University 87 https://civilrights.org/edfund/resource/nypds-infamous-stop-and-frisk-policy-found-unconstitutional/ 88 https://www.rand.org/pubs/tools/TL261/better-policing-toolkit/all-strategies/zero-tolerance.html
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Also related is the practice of “saturation policing.” A 2017 Georgetown study shows:
The saturation of certain neighborhoods suggested extremely tight surveillance and disruption of everyday movements primarily of young Black males. In the Floyd v. City of New York trial on constitutional violations in the conduct of stop and frisk activity, one of the litigated facts was that police stops were concentrated in neighborhoods with high percentages of Black and Latino residents, net of the influence of local crime rates.89
Saturating communities of color with police is counter-productive in two ways. It is a very inefficient way to locate and apprehend violent actors, as police attention is spread throughout an entire community rather than focused on the small number of perpetrators. It also leads inexorably to racial profiling, excessive force, and mass incarceration.
A proposal has been introduced for the Berkeley City Council to create a Crime Suppression Unit within the police department. Little information on this Unit has been released, but sponsors refer to the Drug Task Force that operated in the historically African American district of South Berkeley for many years. The DTF incorporated many of the worst elements of saturation policing, aggressive policing, stop-and-frisk, and the national “drug war.” It had a reputation in the Black community for abusive tactics, racial profiling, and the targeting of an entire population regardless of any evidence of criminal conduct.
No policing unit be developed that uses these discredited policing tactics. They are unfair and damaging to Black and Brown communities, reinvigorating the regime of mass incarceration, called “the New Jim Crow,” that has not yet been dismantled.90 And they do not work, because they waste police resources that should be used to solve violent crime by instead focusing on low-level offenders or simply on community members who may fit a racial profile. Instead, Berkeley must put our moral, organizational, and financial resources behind a new vision of “holistic, equitable and community-centered safety” as discussed elsewhere in this report.
89 https://www.law.georgetown.edu/georgetown-law-journal/wp-content/uploads/sites/26/2019/10/fagan-new- policing-new-segregation_ACCESSIBLE.pdf
90 https://newjimcrow.com/
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Office of the City Manager
2180 Milvia Street, Berkeley, CA 94704 ● Tel: (510) 981-7000 ● TDD: (510) 981-6903 ● Fax: (510) 981-7099 E-Mail: [email protected] Website: http://www.CityofBerkeley.info/Manager
ACTION CALENDAR
March 10, 2022
To: Honorable Mayor and Members of the City Council
From: Dee Williams-Ridley, City Manager
Submitted by: Lisa Warhuus, Director, Health, Housing, and Community Services Subject: Presentation and Discussion of Reports Submitted by Reimaging Public Safety Task Force and National Institute for Criminal Justice Reform
SUMMARY
On July 14, 2020, in Resolution No. 69, 501-N.S. City Council passed a package of items providing direction for the development of a new paradigm of public safety in Berkeley. As part of the items that were adopted, City Council adopted Item 18c (Referral to City Manager to Re-imagine Policing Approaches to Public Safety Using a Process of Robust Community Engagement, to Develop a Path Forward to Transforming Public Safety and Policing in Berkeley) and Item 18d (“Transform Community Safety and Initiate a Robust Community Engagement”) which directs the City Manager to engage a qualified firm(s) or individual (s) to lead a robust, inclusive, and transparent community engagement process with the goal of achieving a new and transformative model of positive equitable and community centered safety for Berkeley.
Council will hear from both the National Institute for Criminal Justice Reform and from the Reimaging Public Safety Task Force with two reports with creative approaches to address the council direction. City Staff will receive community feedback and collect additional information from council with the goal of returning in April 2022 with a report and recommendations on a path forward to transforming public safety and policing in Berkeley. However since the Specialized Care Unit is an integral part of the future we have included this report which provides the Specialized Care Unit (SCU) Steering Committee’s response to the recommendations from Research Development Associates (RDA) for the implementation of Berkeley’s SCU. Considerations from this response will be incorporated into SCU implementation planning along with RDA’s recommendations.
CURRENT SITUATION AND ITS EFFECTS
As part of its Re-Imagining Public Safety process, the City of Berkeley has been engaged in planning to implement a SCU. The City contracted with RDA to conduct best practice research and a community engagement process in order to make recommendations for the best SCU model for Berkeley. To oversee and advise on this process, the City formed an SCU Steering Committee consisting of representatives from the Health, Housing, and Community Services Department, the Berkeley Fire
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Department, appointees of the Mental Health Commission, and community representatives from the Berkeley Community Safety Coalition.
With guidance from the Steering Committee, RDA created three reports. The first report provides detailed information about 37 alternative crisis response models that have been implemented in the United States and internationally. The second report provides information about Berkeley’s current crisis response system and also summarizes stakeholder perspectives gathered through a deep community engagement process conducted by RDA, in which input was gathered from utilizers of Berkeley’s crisis response services, local community-based organizations (CBOs), local community leaders, and City of Berkeley and Alameda County agencies. RDA’s third and final report utilized information gathered in completing the first two reports and makes specific recommendations for an SCU model for Berkeley. RDA’s twenty-five recommendations are below, followed by the Steering Committee’s response to these recommendations.
RDA RECOMMENDATIONS FOR AN SCU FOR BERKELEY
RDA’s recommendations are categorized into five sets as follows:
Recommendations 1-7: The SCU Mobile Team
1. The SCU should respond to mental health crises and substance use emergencies without a police co-response.
2. The SCU should operate 24/7.
3. Staff a three-person SCU mobile team to respond to mental health and substance use emergencies.
4. Equip the SCU mobile team with vans.
5. The SCU mobile team should provide transport to a variety of locations.
6. Equip the SCU mobile team with supplies to meet the array of clients’ needs.
7. Clearly distinguish the SCU from the Mobile Crisis Team.
Recommendations 8-10: Assessing the SCU Crisis Response: Dispatch & Alternative Phone Number
8. Participate in the Dispatch assessment and planning process to prepare for future integration.
9. Ensure the community has a 24/7 live phone line to access the SCU.
10.Plan for embedding a mental health or behavioral health clinician into Dispatch to support triage and SCU deployment.
Recommendations 11-14: Implement a Comprehensive 24/7 Mental Health Crisis Response Model
11.Fully staff a comprehensive model to ensure the success of the SCU mobile team, including supervisory and administrative support.
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12.Operate one SCU mobile team per shift for three 10-hour shifts.
13.SCU staff and Dispatch personnel should travel to alternative crisis programs for in-person observation and training.
14.Prepare the SCU mobile team with training.
Recommendations 15-23: Administration and Evaluation
15.Contract the SCU model to a CBO.
16.Integrate the SCU into existing data systems.
17.Collect and publish mental health crisis response data publicly on Berkeley’s Open Data Portal.
18.Implement care coordination case management meetings for crisis service providers.
19.Implement centralized coordination and leadership across city agencies to support the success of mental health crisis response.
20.Continue the existing SCU Steering Committee as an advisory body.
21.Solicit ongoing community input and feedback.
22.Adopt a rapid monitoring, assessment, and learning process.
23.Conduct a formal annual evaluation.
Recommendations 24-25: Promoting Public Awareness
24.Launch a public awareness campaign to promote community awareness and education about the SCU.
25.The SCU mobile team should conduct outreach and build relationships with potential service utilizers.
SCU STEERING COMMITTEE RESPONSE
Following completion of RDA’s final report, the SCU Steering Committee (Committee) held detailed discussions and further analyzed each category of recommendations. The purpose of these discussions, which occurred over two 90-minute meetings in January 2022, was to establish where there was broad agreement among steering committee members and where individual members differed, and also to add additional considerations where needed. While there was strong agreement among steering committee members with most of RDA’s recommendations, there were some nuances and additional considerations that should be considered as part of SCU implementation.
Recommendations 1-7: The SCU Mobile Team
The Committee supports these recommendations with a few points of added clarification. Related to the first recommendation (respond to mental health crises and substance use emergencies without a police co-response), the Committee agrees that the SCU should maintain its independence from the Berkeley Police Department (BPD), however acknowledges that there may be incidents that involve a threat of violence. In
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these exception cases, the SCU should have protocols to activate BPD to provide support. Similarly, the Committee recommends that if BPD is called to respond to a mental health and/or substance use crisis, and there is no threat of violence present, they should be able to transfer the client to an SCU response.
Regarding the third recommendation (staff a three-person SCU mobile team to respond to mental health and substance use emergencies), the Committee believes that the level of required medical expertise on the SCU should be flexible, given constraints in hiring and potential lack of qualified candidates. There was some disagreement among Committee members about the level of medical expertise necessary on the SCU team.
While one member in particular noting that a “peer” with basic medical training may be sufficient and more relatable, most members agreed that SCU users could benefit from a higher level of medical expertise that could be applied on the spot. The Committee also identified that, while the type of medical expertise could vary, it would be ideal to have a SCU member who could identify a medical need due to drug use versus a preexisting condition, such as an infected wound from using needles.
Not providing adequate medical expertise, instead relying on the Fire Department to provide urgent medical attention as needed, may result in patients being transported to the hospital, where there may be a lack of continued care. Ensuring some amount of medical expertise on the SCU will help maintain the spirit of the Unit to provide holistic care to individuals in crisis. This will continue to evolve in the implementation of the pilot program.
Recommendations 8-10: Assessing the SCU Crisis Response: Dispatch & Alternative Phone Number
The Steering Committee agrees with recommendations 8 and 9, yet would like to recommend an alternative to recommendation 10 (plan for embedding a mental health or behavioral health clinician into Dispatch to support triage and SCU deployment). The Committee agrees that it is important for the SCU to be well-coordinated with the 911 Communications Center, which is currently under the Berkeley Police Department, but does not agree that the behavioral health clinician, with mental health and substance use expertise, needs to physically sit in the dispatch space. The Committee is concerned that co-locating this individual with 911 Dispatch could lead to a misconception, and resulting lack of trust, about whether or not the SCU includes a police response. The Committee was also concerned that it would be challenging for an embedded individual with a unique roll that is a stretch beyond the current dispatch culture. Currently, most dispatch communications protocols are general and not tailored to responding to behavioral health calls, which could lead to law enforcement being deployed, instead of the SCU. During the implementation phase, the Committee recommends that the individual who provides dispatch services for the SCU should receive training, build relationships with the 911 Communications Center to ensure coordinated deployment of the appropriate resource, and should be physically located near or at the location where the rest of the SCU staff is stationed. This training would
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be in addition to training recommended for existing dispatch staff to help them assign calls and effectively utilize the SCU.
Recommendations 11-14: Implement a Comprehensive 24/7 Mental Health Crisis Response Model
The Steering Committee offered additional suggestions to recommendations 11, 13, and 14. For 11, the Committee acknowledges that despite difficulty hiring new staff, it will be good to plan for redundancy in hiring to be able to keep the SCU fully-staffed for all shifts to provide continued coverage when staff are on vacation, sick, etc.
Additionally, the team should avoid creating silos based on technical expertise by hiring a supervisor who is cross-trained in each of the different fields to help with team cohesion. This cross-training will be especially useful for a supervisor who is familiar with mental health and substance use, including harm reduction techniques and medication-assisted treatment (MAT). It is the Committee’s view that this will support individuals who use drugs and desire to engage in this service delivery.
As the SCU moves into the implementation phase, the Committee supports the recommendation for team members to travel to other cities to learn from similar teams, and emphasizes that the Peer Supervisor should also be included in these visits. These training opportunities should focus on teams with a variety of expertise including:
behavioral health, mental health, substance use, harm reduction techniques, and MAT.
This will support cross-training and provide additional context for the Peer Supervisor to help support a successful team. Additionally, the Steering Committee recognizes that there are a variety of trainings that will be applicable and necessary for the SCU before they begin responding in the community. It will be important to prioritize specific trainings in the initial rollout, and add more trainings as the SCU progresses. While training is important, it must be balanced with the urgent need to fill this crisis response gap in the Berkeley community.
Recommendations 15-23: Administration and Evaluation
The SCU Steering Committee supports these recommendations and wants to make sure that the City will maintain a coordinated and collaborative relationship with the contracted Community-Based Organization (CBO). The City of Berkeley, in partnership with the SCU Steering Committee, will continue to discuss the exact parameters of contracting the work of the SCU to a CBO. This contract will be different than a traditional contract, given the required integration with current City services, and partnership across City departments. In addition, the Steering Committee recognizes that providing a physical space for the SCU may be a hurdle given Berkeley’s geography. The implementation group should think creatively to provide a useful space to serve the staff, even if it means looking just outside Berkeley borders (i.e. North Oakland, Albany).
Developing a finance strategy will be critical for the long-term sustainability of the SCU.
Inherent in developing a contract with a CBO will be the identification of known funding
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for a considerable period of time, as no CBO will agree to stand something up this big for a short period of time without a plan for continuity. Recommendations 15-23 do not speak explicitly to financing the SCU (this is in the latter part of the report under the section “Systems Recommendations”) but should have been named here more explicitly since it is fundamental to Administration and Evaluation. The Committee anticipates that funding will be a combination of state and federal funding for crisis response services, as well as Medi-Cal reimbursement of crisis services. The Committee recommends pulling a finance team together early to start strategizing how the SCU will be funded long term through this variety of sources.
Recommendations 24-25: Promoting Public Awareness
The Steering Committee supports these recommendations and further recommends relying on multiple forms of direct outreach and broader communications, given the City of Berkeley’s limited messaging capacity. The Committee believes that the City of Berkeley should leverage the work of trusted partners to provide education about the SCU, such as the Lifelong Medical Street Medicine team. As the SCU gets started, members of the Unit should also conduct field outreach to introduce themselves, explain their duties, and provide a way to contact if needed. This field outreach will help build trust in the early stages.
BACKGROUND
RDA’s recommendations, along with considerations generated in this response by the Steering Committee, will inform implementation of the SCU.
In its third report, RDA also provided a set of “Systems Recommendations” that the Committee did not address for this report, but will address as part of implementation and sustainability planning. These are addressed thoroughly in the report and include:
Addressing the needs of dispatch
A sufficient investment of resources
The role of trust
The report concludes with “Next Steps and Future Considerations” (also not addressed for this report) and include discussion of:
Long-term sustainable funding
The location of 911 dispatch within the Berkeley Police Department Preventing social monitoring: clarifying the SCU’s guiding principles Address the full spectrum of mental health and substance use crisis needs
ENVIRONMENTAL SUSTAINABILITY AND CLIMATE IMPACTS
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There are no identifiable environmental effects or opportunities associated with the subject of this report.
POSSIBLE FUTURE ACTION
The City of Berkeley, in partnership with the SCU Steering Committee, will move into the implementation phase of the Specialized Care Unit.
FISCAL IMPACTS OF POSSIBLE FUTURE ACTION
Implementing the SCU will require significant funding. In addition to funding the operations, it will require staff time across several City departments, which may have varying financial impacts depending on the staff member’s department. Additionally, the City anticipates releasing a Request for Proposals to recruit a community-based organization to serve as lead agency for the Specialized Care Unit and hiring a consultant in healthcare finance to develop a fiscal strategy for sustainability. These contracts will be funded through previously allocated American Rescue Plan Act funding. Identifying sustainable long-term funding for the SCU is an important next step, as described above.
CONTACT PERSON
Lisa Warhuus, Director, Health, Housing, and Community Services, (510) 981-5404.
Attachments:
1: City of Berkeley Crisis Models Report (Research Development Associates) 2: City of Berkeley Mental Health Crisis Response Services and Stakeholder Perspectives Report (Research Development Associates)
3: City of Berkeley Specialized Care Unit Crisis Response Recommendations (Research Development Associates)
4: National Institute for Criminal Justice Reform Final Report and Implementation Plan
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City of Berkeley
Specialized Care Unit Model Recommendations
Crisis Response Models Report
Caroli
ne de Bie
Sarah Ferrell
Sasha Gayle-Schneider
Jamie Dorsey
Nicole Gamache-Kocol
Kevin Wu
This report was developed by Resource Development Associates under contract with the City of Berkeley Health, Housing & Community Services Department.
Resource Development Associates, September 2021
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Table of Contents
Introduction 4
Crisis Response Models: An Overview 6
Components of Crisis Response Models 8
Program Administration 23
Program Planning Process 28
Lessons Learned 32
Appendices 36
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Introduction
In response to the killing of George Floyd by Minneapolis police in May 2020 and the ensuing protests across the nation for this and many other similar tragedies, a national conversation emerged about how policing can be done differently in local communities. The Berkeley City Council initiated a broad reaching process to reimagine policing in the City of Berkeley. As part of that process, in July 2020, the Berkeley City Council directed the City Manager to pursue reforms to limit the Berkeley Police Department’s scope of work to “primarily violent and criminal matters.” These reforms included, in part, the development of a Specialized Care Unit (SCU) pilot to respond to mental health crises without the involvement of law enforcement.
In order to inform the development of an SCU, the City of Berkeley contracted with Resource Development Associates (RDA) to conduct a feasibility study that includes community-informed program design recommendations, a phased implementation plan, and funding considerations. As part of this feasibility study, RDA reviewed the components of nearly 40 crisis response programs in the United States and internationally, including virtually meeting with 10 programs between June and July 2021. This report provides a synthesized summary of RDA’s findings, including common themes that emerged from across the programs, how they were implemented, considerations and rationale for design components, and overall key lessons learned. Please see the table below for a list of the programs that RDA reviewed. For the first nine programs listed (in bold and italics), RDA conducted phone interviews with representatives to obtain a further understanding of their program models; these programs are cited more often in this report because RDA had more details about them. For the remaining programs listed, RDA reviewed information that was available online. For a tabular summary of the key components of each crisis response program that RDA reviewed, please see Appendix C at the end of this report.
Additionally, SAMHSA’s summary of its National Guidelines for Behavioral Health Crisis Care (released in 2020) is included in Appendix A of this report.
Program Name Location
B-HEARD (the Behavioral Health Emergency Assistance
Response Division)
New York, NY
Crisis Assistance Helping Out On The Streets (CAHOOTS) Eugene, OR Crisis Response Pilot Chicago, IL
Expanded Mobile Crisis Outreach Team (EMCOT) Austin, TX Mental Health First / Anti-Police Terror Project Sacramento and Oakland, CA
Portland Street Response Portland, OR
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Program Name Location
REACH 24/7 Crisis Diversion Edmonton, Alberta,
Canada
Support Team Assisted Response (STAR) Denver, CO
Street Crisis Response Team (SCRT) San Francisco, CA
Albuquerque Community Safety Department Albuquerque, NM Boston Police Department’s Co-Responder Program Boston, MA Community Assessment & Transport Team (CATT) Alameda County, CA Community Paramedicine California (statewide)
Crisis Call Diversion Program (CCD) Houston, TX
Crisis Now National model (via
SAMHSA)
Crisis Response Unit Olympia, WA
Cuyahoga County Mobile Crisis Team Cuyahoga County,
Ohio
Department of Community Response Sacramento, CA
Department of Community Solutions and Public Safety Ithaca, NY Downtown Emergency Service Center (DESC) Mobile Crisis
Team
King County, WA
Georgia Crisis & Access Line (GCAL) Georgia (statewide) Los Angeles County Department of Mental Health – ACCESS Center
Los Angeles County,
CA
Los Angeles County Department of Mental Health – Co-
Response Program
Los Angeles County,
CA
Los Angeles County Department of Mental Health –
Psychiatric Mobile Response Teams (PMRT)
Los Angeles County,
CA
Mobile Assistance Community Responders of Oakland
(MACRO)
Oakland, CA
Mental Health Acute Assessment
Team (MHAAT)
Sydney, Australia
Mental Health Mobile Crisis Team (MHMCT) Nova Scotia, Canada Mobile Crisis Assistance Team (MCAT) Indianapolis, IN
Mobile Crisis Rapid Response Team (MCRRT) Hamilton, Ontario, Canada
Mobile Emergency Response Team for Youth (MERTY) Santa Cruz, CA Mobile Evaluation Team (MET) East Oakland, CA
Psykiatrisk Akut Mobilitet (PAM) Unit, the
Psychiatric Emergency Response Team
Stockholm, Sweden
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Program Name Location
Police and Clinician Emergency Response (PACER) Australia (several locations)
Seattle Crisis Response Team Seattle, WA
Street Triage England (several
locations)
Therapeutic Transportation Pilot Program/Alternative Crisis Response
Los Angeles City and
County, CA
Toronto Crisis Response Toronto, Ontario,
Canada
Crisis Response Models: An
Overview
Of the crisis response program models reviewed, almost all specify that they respond to mental health and behavioral health concerns in their communities. Some models additionally specify that they respond to non- emergency calls, crises or disturbances related to substance use, homelessness, physical assault and sexual assault, family crises, and/or youth-specific concerns, as well as conduct welfare checks.
In California, Alameda County has the highest rate of 5150 psychiatric holds in the entire state.
1 Of those Alameda County individuals placed on
a 5150 psychiatric hold that were transferred to a psychiatric emergency services unit, 75-85% of the cases did not meet medically necessary criteria to be placed in inpatient acute psychiatric services. This demonstrates an overuse of emergency psychiatric services in Alameda County, which creates challenges in local communities such as having lengthy wait times for ambulance services when these ambulances are tied up transporting and waiting to discharge individuals on 5150 holds at psychiatric emergency service units.
Mental health crises are varied - they affect individuals across their lifespans, manifest in a variety of behaviors, and exist on a spectrum of
1 INN Plan – Alameda County: Community Assessment and Transport Team (CATT) – October 25, 2018. (2018, October 25). California Mental Health Services Oversight and Accountability Commission. http://www.mhsoac.ca.gov/document/inn-plan-alameda-county- community-assessment-and-transport-team-catt-october-25-2018 & https://mhsoac.ca.gov/sites/default/files/documents/2018- 10/Alameda_INN%20Project%20Plan_Community%20Assessment%20and %20Transport%20Team_8.6.2018_Final.pdf
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severity and risk. A crisis response system ultimately seeks to provide care to individuals in the midst of a mental health crisis, keeping the individual and their surrounding community safe and healthy, and preventing the escalation of the crisis or exacerbating strains to mental and emotional well-being. As such, there are many considerations for the design of a mental health crisis response system that addresses the current shortcoming or flaws in existing models around the country and internationally.
Traditionally, the U.S. crisis response system has been under the purview of local police departments, typically with the support of local fire departments and emergency medical services (EMS), and activated by the local 911 emergency phone line. Over time, communities have responded to the need for a response system that better meets the mental health needs of community members by activating medical or therapeutic personnel in crisis response instead of traditional first responders (i.e., police, fire, EMS).
Term Definition
Traditional Crisis
Response Model
For the purposes of this report, we assume a
traditional crisis response model includes having all
crises routed through a 911 center that then
dispatches the local law enforcement agency (as
well as fire department and/or EMS, if necessary) to
respond to the crisis.
Co-Responder
Model
Co-responder models vary in practice, but they
generally involve law enforcement officers and
behavioral health clinicians working together to
respond to calls for service involving an individual
experiencing a behavioral health crisis.
911 Diversion
Programs
Programs with processes whereby police, fire, and
EMS dispatchers divert eligible non-emergency,
mental health-related calls to behavioral health
specialists, who then manage crisis by telephone
and offer referrals to needed services.
Alternate Model
Emerging and innovative behavioral health crisis
response models that minimize law enforcement
involvement and emphasize community-based
provider teams and solutions for responding to
individuals experiencing behavioral health crises.
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with a mental health illness compared to others without a mental illness.2 A November 2016 study published in the American Journal of Preventative Medicine estimated that 20% to 50% of fatal encounters with law enforcement involved an individual with a mental illness. 3 As a result,
communities have begun to consider the urgent need for crisis response models that include mental health professionals rather than police.
In the current national discussion about appropriate crisis response strategies for individuals experiencing mental health crises, the prominent concerns voiced have typically focused on the safety of crisis responders and community members, the funding of such programs, and balancing a sense of urgency to implement new models quickly with the need for intentional planning and preparation. In order to understand the current models that exist, RDA reviewed nearly 40 national and international crisis response programs and specifically interviewed staff from 9 programs about their:
● Program planning efforts, including community engagement strategies, coordinating across city agencies and partner organizations, and program planning, implementation, and evaluation activities;
● Models’ key elements, including dispatch, staffing, transport capabilities, follow-up care, and more;
● Program financing;
● Other considerations that were factored into their program planning; and
● Key lessons learned or advice for the City of Berkeley’s implementation of its SCU.
Components of Crisis Response
Models
While each crisis response program was designed to meet the needs of its local community, there are several overarching components that were common across the programs that RDA explored. The majority of crisis response programs use their community’s existing 911 infrastructure for dispatch. Most programs respond to mental health and behavioral health calls where they engage in de-escalation, assessment, referral, and
2 Szabo, L. (2015, December 10). People with mental illness 16 times more likely to be killed by police. USA Today.
https://www.usatoday.com/story/news/2015/12/10/people-mental- illness-16-times-more-likely-killed-police/77059710/
3 DeGue, S., Fowler, K.A., & Calkins, C. (2016). Deaths Due to Use of Lethal Force by Law Enforcement. American Journal of Preventive Medicine, 51 (5), S173-S187. https://www.ajpmonline.org/article/S0749-3797(16)30384- 1/fulltext
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transport. Nearly all programs recognize the need to operate 24/7.
Staffing structure varies by the needs of the community, but many response team units are staffed by teams of two to three individuals and can include a combination of mental health professionals, physical health professionals, and peers with lived experience. Many teams arrive in plainclothes or T-shirts with logos in a vehicle equipped with medical and engagement items. Teams typically receive skills-based training in de- escalation, crisis intervention, situational awareness, and communication.
Crisis teams will either transport clients themselves or call a third party to transport, depending on the legal requirements and staffing structure of the crisis response team. Programs varied in their inclusion and provision of follow-up care.
Underneath the high-level similarities of the crisis response models that RDA researched are the tailored nuances that each program adapted to its local needs, capacities, and priorities. Below are additional details, considerations, and examples from existing models to further inform the City of Berkeley’s development and implementation of its SCU.
Accessing the Call Center
Of the reviewed crisis response programs, the majority use the existing local 911 infrastructure, including its call receiving and dispatch technology and staff. There are several advantages to this approach. The general public is typically familiar with the number and process for calling 911, which can reduce the barrier for accessing services. Also, because 911 call centers already have a triage protocol for behavioral health calls, there can be a more seamless transfer of these types of calls to the local crisis response program. Additionally, some calls might not be reported as a mental health emergency but can be identified as such by trained 911 dispatch staff.
Generally, the administration of 911 varies across the nation. In some locales, 911 is operated by the police department, while in other locales it is administered centrally across all emergency services. Some programs have mental health staff situated in the 911 call center to: a) directly answer calls; b) support calls answered by 911 staff; and/or c) provide services over the phone as a part of the 911 call center’s response. In Chicago, in addition to diverting more calls to the crisis response program, the staff of Chicago’s Crisis Response Pilot anticipates that having mental health clinicians embedded in their call center to do triage and telemedicine will help them lay the foundation for a smooth transition to 988.
988 is the three-digit phone call for the National Suicide Prevention Lifeline.
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counselors.4 In California, AB 988 was passed in the State Assembly on June 2, 2021(and is currently waiting on passage by the State Senate) – AB 988 seeks to allocate $50 million for the implementation of 988 centers that have trained counselors receiving calls, as well as a number of other system-level changes.5 In RDA’s research of crisis response models, some programs are actively planning for the upcoming 988 implementation when exploring the functionalities of their local 911 infrastructure and responsibilities; other programs were not differentiating 988 from 911 in the communities. For the purposes of this report, moving forward, we will not differentiate 911 from 988, and will refer to all emergency calls for service as going to 911.
Other programs use an alternative phone number in addition to or instead of 911. These numbers can be an existing non-emergency number (like 211) or a new phone number that goes directly to the crisis response program. Oftentimes a program will utilize an alternative phone number when they believe that people, particularly those disproportionately impacted by police violence, do not feel safe calling 911 because they fear a law enforcement response. Portland’s Street Response team & Denver’s STAR team use both a non-emergency number and 911, routed to the same call center. This supports community members that are hesitant to use 911 while also ensuring that calls that do come through 911 are still routed to Portland’s Street Response team. Overall, designing a system in Portland with both options was intended to increase community members’ access to mental health crisis services. Given that Portland’s program began on February 16, 2021, not enough time has elapsed for findings to be generated regarding the success of this model. But a current challenge that Portland shared with RDA is that some calls to their non-emergency number have wait times upwards of an hour because their call center needs to prioritize 911 calls.
In other program models, an alternate phone number may have been used in the community for years and, therefore, is a well-known resource.
For example, in Canada’s REACH Edmonton program, the 211 line is well- used for non-emergency situations, so it is used as the main connection point for its crisis diversion team.
Triage & Dispatch
Once a call is received, dispatch or call center staff will assess whether services could be delivered over the phone or whether the call requires an in-person response, and whether the response should be led by the crisis response team or another entity. Several programs utilize existing
4 Federal Communications Commission. (2021). Suicide Prevention Hotline. https://www.fcc.gov/suicide-prevention-hotline &
https://www.fcc.gov/sites/default/files/988-fact-sheet.pdf 5 Open States. (n.d.). California Assembly Bill 988. Retrieved September 2, 2021, from https://openstates.org/ca/bills/20212022/AB988/ Attachement 1
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well-used triage tools and/or made modifications to those triage tools based on a renewed emphasis of having non-police responses for mental health crises. Please see Appendix B for sample outlines of types of scenarios for crisis response teams that were shared with RDA. A dispatch’s assessment of mental health related calls is dependent on the services provided by the local mental health crisis response team, an assessment of the situation and the caller’s needs, who the caller has identified as the preferred response team, and any other safety concerns.
Some programs prioritize staff assignment based on call volume and need, such as programs that have chosen to pilot non-police crisis response teams in specific geographic locations within their jurisdiction. In these programs, the call center must, therefore, determine the location of the requested response when dispatching a crisis response team. For example, Chicago’s Crisis Response Pilot has four teams that are assigned to different areas of the city based on their local ties and expertise of community needs; each team, therefore, only responds to calls that come from their assigned area. When programs are able to scale their services and hire more staff, many pilot programs plan to expand their geographical footprints.
Many crisis response teams are dispatched via radio or a computer-aided dispatch (CAD) system, and some have the ability to listen in on police radio and activate their own response if not dispatched. Of the nine programs that RDA interviewed, the Eugene CAHOOTS program allows its team to be self-dispatched, the Denver STAR program allows its team to directly see what calls are in the queue so they can be more proactive in taking and responding to calls, and the San Francisco SCRT program allows its team to respond to incidences that they witness while being out in the streets. Regarding the ability to self-dispatch, San Francisco’s SCRT program is currently figuring out the regulatory requirements that might prohibit self-dispatching paramedics because they must be dispatched through a dispatch center.
Having multiple opportunities to engage the crisis response team is important to ensure community members have the most robust access to the service. For example, in Denver, their police, fire, and EMS can call their Support Team Assisted Response (STAR) team directly. Across all incidents that the Denver STAR team responded to in the first six months of its pilot implementation, it was activated by 911 dispatch in 42% of incidents, by police/fire/EMS in 35% of incidents, and self-activated in 23% of incidents.
6 These data from the Denver STAR team demonstrate how, especially in the early stages of a new program’s implementation, new processes and relationships are continually being developed, learned, refined, and implemented. For this reason, it is beneficial to have safeguards in place in triage and dispatch processes so that the crisis
6 Denver STAR Program. (2021, January 8). STAR Program Evaluation. https://www.denverperfect10.com/wp-
content/uploads/2021/01/STAR_Pilot_6_Month_Evaluation_FINAL- REPORT.pdf
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response team can be flexible in responding to the various ways in which crisis response calls originate.
Assessing for Safety
The presence of weapons or violence are the most common reasons why a crisis response team would not be sent into the field. Some of the reviewed programs only respond to calls in public settings and do not go to private residences as an effort to protect crisis team staff, though this was the case in a few of the 40 reviewed programs. Calls that are deemed unsafe or not appropriate for a crisis response team will often be responded to by police, co-responder teams, police officers trained in Critical Intervention Team (CIT) techniques, or other units within the police department. Many alternative models have demonstrated that the need for a police response is rare for calls that are routed to non-law enforcement involved crisis response teams. For instance, in 2019, Eugene’s Crisis Assistance Helping Out On The Streets (CAHOOTS) team only requested police backup 150 times out of 24,000 calls, or in fewer than one percent of all calls received by the crisis team;7 this demonstrates that effective triage assessments and protocols do work in crisis response models.
Several of the programs interviewed by RDA mentioned that they are currently evaluating options for their non-police crisis response teams to respond to situations that may involve weapons or violence. These are situations that would otherwise be scenarios that default to a police response. These programs are aware of the risks of police responses to potentially escalate situations that could otherwise be deescalated with non-police involved responses and are trying to find ways to reduce those types of risks.
The types of harm and concerns for safety that should be assessed are not only for crisis response team staff, but also for the individual(s) in crisis and surrounding bystanders or community members. SAMHSA’s best practices on behavioral health crisis response underscores that effective crisis care is rooted in ensuring safety for all staff and consumers, including timely crisis intervention, risk management, and overall minimizing need for physical intervention and re-traumatization of the person in crisis. 8 When call center
staff deem a call safe and appropriate for the crisis response team, they will assign the call to the crisis response team. There may be multiple calls and situations happening concurrently, in which case the call center staff
7 White Bird Clinic. (n.d.). What is CAHOOTS?. Retrieved August 29, 2021, from https://whitebirdclinic.org/what-is-cahoots/
8 Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). Crisis Services – Meeting Needs, Saving Lives.
https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PE P20-08-01-001%20PDF.pdf (page 32)
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prioritize the calls based on pre-established criteria, such as acuity and risk of harm.
Crisis Response Teams Increase Community Safety
New York City’s Behavioral Health Emergency Assistance Response Division (B-HEARD) program is being piloted in a region that receives the city’s highest number of mental health emergency calls.
9 In the first month of implementation, the program
demonstrated:
● Increased rates of people accepting care from the B-
HEARD team compared to traditional 911 response teams.
● The proportion of people transported by the crisis response team to the hospital for more care was far smaller than the proportion transported with their traditional 911 response. ● An anticipated increase of 911 operators routing mental health emergency calls to the B-HEARD team.
“A smarter approach to public health and public safety. A smarter use of resources. And the evidence — from Denver to New York — shows that responding with care works.”
- U.S. Representative Jamaal Bowman, D-NY
Hours of Operation
Because a mental health crisis can happen at any time, many programs have adopted a 24-hour model that supports the community seven days a week; of the 40 programs that RDA reviewed, 12 have adopted a 24/7 model. Some programs that are in their early phases of implementation have launched with initially limited hours but have plans to expand to 24/7 coverage once they are able to hire more staff for crisis response teams. If a program uses 911 as a point of access for the crisis response team, then there may be a community perception or expectation that the crisis response team also operates 24/7 the same way that 911 operates 24/7.
Other programs with more restricted resources often have limited hours; some offer services during business hours (9am to 5pm, Monday through Friday) while others offer services after-hours. Using historical data to prioritize coverage during times with highest call volumes can help a program adapt to local needs. For example, Mental Health First Oakland currently responds to calls Friday through Sunday from 7pm to 7am
9 Shivaram, D. (2021, July 23). Mental Health Response Teams Yield Better Outcomes Than Police In NYC, Data Shows. National Public Radio (NPR). https://www.npr.org/2021/07/23/1019704823/police-mental-health-crisis- calls-new-york-city#:~:text=Hourly%20News-
,New%20York%20City%20Mental%20Health%20Response%20%20Teams%2 0Show%20Better%20Results,were%20admitted%20to%20the%20hospital.
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because they have found that those times are when mental health services are unavailable but need is high.
Types of Calls
Some crisis response programs only respond to specific call types, such as calls pertaining to mental health, behavioral health, domestic violence, substance use, or homelessness. A fraction of programs only respond to acute mental health situations, such as suicidal behavior, or conversely only non-acute mental health calls, such as welfare checks. And, some crisis response programs respond to any non-emergency, non-violent calls, which may or may not include mental health calls. Every program is unique in the calls that they are currently responding to as well as how agencies coordinate for different types of calls. Additionally, given that many programs are actively learning and adapting their models, what and how they respond to calls is evolving.
The most common types of calls that programs are responding to are calls regarding trespassing, welfare checks, suicidal ideation, mental health distress, and social disorder. Several programs mentioned that their main call type - trespassing - is to move an unwanted person, usually someone that is unsheltered and sitting outside the caller’s home or business. While programs provide this service, many advocate for increased public education around interacting with unhoused residents and neighbors without the need to call for a third-party response.
The programs in New York City, Chicago, and Portland shared with RDA that they are keeping their scopes of services small for their current pilot implementations. At a later time, they will learn from the types of calls receive and determinations made in order to determine how they will expand their program to respond to more situations (e.g., including serving more types of crises, more types of spaces like private residences, etc.).
In order to demonstrate the variety of incidents that different programs respond to, below are highlights regarding the types of calls that some of the programs that RDA interviewed respond to:
• New York City’s B-HEARD program is currently responding to calls regarding suicidal ideation with no weapons, mental health crisis, and calls signaling a combination of physical health and mental health issues. For calls where weapons are involved or are related to a crime, NYPD is the initial responder. The B-HEARD program provides transport and linkage to shelters, where the shelters then provide follow-up services.
• Chicago’s Crisis Response Pilot is determining how they will address “low-level crimes” and crimes related to homelessness, especially if the root cause of the crime is an unmet behavioral health and/or housing need. The program does not have an official protocol or decision tree yet for determining which calls it will respond to. But, Attachement 1
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its emphasis is on responding to mental health crisis and mental health needs.
• The Portland Street Response program is currently only responding to calls regarding crises that are happening outdoors or public settings (e.g., storefronts), not in private residences. The majority of their calls are related to substance use issues, co-occurring mental health and substance use issues, and welfare checks. The program cannot respond to suicide calls because of a Department of Justice (DOJ) contract that the City of Portland has that would require the Portland Street Response Program to appear before a judge and renegotiate that contract that the city currently has; this process would take at least two years to happen.
• Denver’s STAR program currently responds primarily to calls where individuals have schizophrenia, bipolar disorder, major depression, and/or express suicidal thoughts but have no immediate plans to act upon them. The STAR program also conducts many Welfare checks. The program is currently primarily dealing with issues related to homelessness because its pilot rolled out in Denver’s downtown corridor where there is a high number of unsheltered individuals.
Services Provided Before, During, and
After a Crisis
The reviewed programs offer a variety of services before, during, and after a mental health crisis. Regarding services provided before crises occur, some programs view their role as supporting individuals prior to crisis, including proactive outreach and building relationships in the community with individuals. Portland’s Street Response team contracts with street ambassadors with lived experience (via a separate contract with a local CBO) that do direct outreach to communities; street ambassadors work to explain the team’s services and ultimately increase trust. Portland’s Street Response team also works with nursing students who provide outreach and medical services to nearby encampments. Mental Health First has a strong cohort of repeat callers who request accompaniment through issues they are facing that the team will go into the field to provide – these services can help them avoid escalating into a crisis. Denver’s STAR program initiates outreach with local homeless populations to ensure they have medicines and supplies. These proactive efforts are examples of crisis response teams supporting potential individuals before they are in crisis, and thus also promoting their overall health and well-being.
During a crisis response, most programs offer various crisis stabilization services, including de-escalation, welfare checks, conflict resolution and mediation, counseling, short-term case management, safety planning, assessment, transport (to hospitals, sobering sites, solution centers, etc.), and 5150 evaluations. To engage the individual in crisis, staff will provide supplies to help meet basic needs with items such as snacks, water, and clothing. If there is a medical professional on the team, they can provide Attachement 1
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medical services including medical assessments, first aid, wound care, substance use treatment (i.e., medicated-assisted treatment), medication assistance and administration, and medical clearance for transport to a crisis stabilization unit (CSU).
After a crisis, the teams may provide linkage to follow-up care. Some crisis response teams do short-term case management themselves, but most refer (and sometimes transport) individuals to other providers for long-term care. Referrals can be a commonly provided service of a crisis response program. For example, 41% of Denver STAR’s services are for information and referrals.10 Many programs have relationships with local community- based organizations for providing referrals and linkages, while some programs have a specific protocol for referring individuals to a peer navigation program or centralized care coordination services.
10 Alvarez, Alayna. (2021, July 21). Denver’s pilot from police is gaining popularity nationwide. Axios. https://www.yahoo.com/now/denver-pivot- police-gaining-popularity-122044701.html
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Term Definition
Transport
Placing an individual in a vehicle and driving them
to or from a designated mental health service or
any other place.
5150
5150 is the number of the section of the Welfare
and Institutions Code which allows an adult who is
experiencing a mental health crisis to be
involuntarily detained for a 72-hour psychiatric
hospitalization when evaluated to be a danger to
others, or to himself or herself, or gravely disabled.
Peer Worker
A mental health peer worker utilizes learning from
their own recovery experiences to support other
people to navigate their recovery journeys.
Medication-
Assisted
Treatment (MAT)
MAT is the use of medications, in combination with
counseling and behavioral therapies, to provide a
whole-patient approach to the treatment of SUDs.
Narcan
Narcan (Naloxone) is a nasal spray used for the
treatment of known or suspected opioid overdose
emergencies.
Crisis Stabilization
Unit
A mental health voluntary facility that provides a
short-term stay for individuals needing additional
stabilization services following a behavioral health
crisis.
Sobering Center
A facility that provides a safe, supportive
environment for publicly intoxicated individuals to
become sober.
Staffing Crisis Teams
Most teams include a combination of a medical professional (e.g., an EMT or nurse), a mental health clinician (e.g., a psychologist or social worker), and a peer. Having a variety of staff on a team allows the program to respond to a diverse array of calls, meet most needs that a client might have, and gives the client the ability to engage with whomever they feel most comfortable.
The reviewed programs staffed their crisis teams with a variety of medical professionals. There was consensus among interviewed programs that crisis response team EMTs, paramedics, nurse practitioners, or psychiatric nurse practitioner clinicians should have at least three to five years of experience in similar settings, as well as having comprehensive de- escalation and trauma-informed care training and skills. Austin’s Extended Mobile Crisis Outreach Team (EMCOT) program cited that a paramedic's ability to address a client's more acute physical health and substance use Attachement 1
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needs is a beneficial diversion away from an EMS or police response.11 However, in many cities, the skills and expertise of paramedics are not heavily utilized, as many mental and behavioral health calls do not require a high level of medical care. However, a medical professional can be an important addition to the team, especially for services like providing first aid, wound care, the administration of single-dose medication, medication-assisted treatment (MAT) for substance use issues, and 5150 transports. Considerations for which medical professionals should be staffed on a crisis team depends on the types of services the model intends to provide, the historical data on the types of calls or service needs, the local rules for which services can be provided by specific professions, and the overall program budget.
All programs had a mental health provider on their crisis response teams.
There is variability in the level of formal education, training, and licensure of the type of mental health provider in each program. Some programs have licensed, masters-level therapists and clinicians (e.g., ASW, LCSW), while other programs utilize unlicensed mental health providers.
Considering if a program wants or needs to be able to bill Medicaid or other insurance payors, the ability to place a 5150 hold, as well as the direct costs of providers with differing levels of education and training are examples of considerations and decision points that programs have when determining what type of professional they want to provide mental health services.
Across the programs reviewed and interviewed by RDA, there is variability in the current presence of peer support specialists on teams. By definition, peer workers are “those who have been successful in the recovery process who help others experiencing similar situations.”12 Studies demonstrate that by helping others engage with the recovery process through understanding, respect and mutual empowerment, peers increase the likelihood of a successful recovery. While they do not replace the role of therapists and clinicians, evidence from the literature and testimonials given to RDA leave no doubt about their value added on a crisis response team. Peer support specialists are able to connect with clients in crisis in ways that are potentially very different from how mental health clinicians and medical providers are trained to provide their specific types of services.
Although 21 of the 40 reviewed programs were classified as alternative models for mental health crisis response, it is important to note that co- responder programs, which were 11 of the 40 reviewed programs, include a police officer on the response team. A co-responder program will often
11 Expanded Mobile Crisis Outreach Team. (n.d.). Integral Care Crisis Services. Retrieved August 29, 2021, from
https://www.austintexas.gov/edims/document.cfm?id=302634 12 Who Are Peer Workers?. (2020, April 16). Substance Abuse and Mental Health Services Administration (SAMHSA) Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TACS). https://www.samhsa.gov/brss-tacs/recovery-support-tools/peers Attachement 1
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be used for higher acuity calls that involve the risk of violence by the person in crisis or the risk that the person in crisis has a weapon. As co- responders, police may arrive on site before the rest of the crisis team does. Other models treat the police officer as a back-up personnel, allowing the crisis team to evaluate the level of risk or danger of the situation and then, if de-escalation tactics are unsuccessful, call the police for support.
Team structures vary depending on funding, local salary structures for different types of providers, program design, and program administration.
For example, 24-hour programs require more teams and staffing while programs with limited hours will likely have fewer shift rotations and therefore fewer teams. San Francisco’s Street Crisis Response Team has six teams with three members per team; shifts are 12 hours long with two teams assigned to each shift. Overlap between the shifts has improved coordination between the teams. Programs with unionized staff (e.g., EMTs, paramedics) require regimented 8-, 10-, or 12-hour shifts, which also influences a team’s capacity and scheduling.
Training
Training requirements vary based on the staffing structure and services provided by a crisis response program as well as the specific needs of the local community. Across the board, programs train their staff in crisis intervention topics such as de-escalation, mental health intervention, substance use management, and situational awareness. Many teams are trained together as a cohort to build relationships and trust between staff.
Most teams are trained for around 40 hours in the classroom and then supervised in the field. In co-responder teams, police officers often receive 40 hours of Crisis Intervention Team (CIT) Training.
Specialized staff also receive specific training relevant to their role.
Dispatch staff typically receive separate training focused on risk assessment and triage. In programs with clinicians embedded within the call center, the clinicians often provide training to other dispatch staff on mental health topics. Interviewed programs also recommended the crisis response team's dispatch team learn to assess call risk level by building an intake/eligibility tool, as well as through risk assessment and motivational interviewing. For both Denver’s STAR and Portland’s Street Response programs, dispatch staff were trained by and then shadowed Eugene’s CAHOOTS dispatch team, leveraging the decades of experience of CAHOOTS’ established alternative crisis response model.
Specific de-escalation and crisis intervention training in which programs participate include key strategies to mitigate risk in the field, learning effective radio communication, and motivational interviewing skills. Some interviewed programs shared that substance use training should be attended by all crisis response staff, not just clinicians; for example, Narcan administration, tourniquet application, and harm reduction training are critical training skills for all team members when supporting a client during a substance use emergency.
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Training on implicit bias was also regarded as essential among interviewed programs. Many interviewed programs agreed that receiving training in team-building and communication strategies, trauma-informed care, cultural competency, and racial equity advances the intention and principles of their alternate response program.
Equipment: Uniforms, Vehicles, and
Supplies
Most teams arrive either in plain clothes or a T-shirt with a logo.
Interviewed programs attested that casual clothing helps crisis response teams appear approachable and creates a sense of comfort for the person in crisis. In contrast, programs worried that formalizing their uniforms could trigger negative past experiences that community members have had with institutions (e.g., police, psychiatric hospitals, prisons) and, therefore, escalate someone in crisis. However, EMTs or police in a co- responder team do wear their usual uniform so that they are easily identifiable as first responders.
The types of vehicles and equipment needed for each model vary based on the scope of services provided, types of calls to which the team responds, and the team’s staffing structure. The majority of programs have a van or fleet of vans with the program logo on it and are stocked with necessary supplies. Some programs use their vehicles for on-site service delivery, while others use them only for transporting a client to an alternate location. Programs situated within fire departments often have EMTs or paramedics on-staff, so those teams ride in ambulances or vans with transport capabilities. Co-responder programs often use police vehicles, either marked or unmarked.
There are several considerations for how the design of the vehicle increases accessibility and safety for clients, as well as supports the security of providers. Vans should be accessible to wheelchairs so that crisis response teams can provide services within the interior of the van (to ensure client privacy) and in the event of a needed transport. Also, vans equipped with lights allow them to park on sidewalks and increase traffic safety. Several interviewed programs mentioned using Eugene’s CAHOOTS program’s van specifications. One component of this design is a plexiglass barrier between the van’s front and back seats, which protects both the driver and anyone riding in the back in the case of an accident; additionally, the barrier keeps clients in the back of the vehicle and protects the driver from any disruption that could decrease safety during the transport. However, some cities are moving away from including the plexiglass barrier between the front and back seats in their vans due to the stigma and lack of trust it communicates to the client.
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assessed and which could potentially use the program’s response. The STAR program teams also have direct access to an electronic health record (EHR) system where they can look-up an individual’s health history or communicate directly with a client’s psychiatrist or case manager and thus provide tailored, high quality of care in real-time.
If crisis response teams provide medical services, they often carry items such as personal protective equipment, wound care supplies, a stethoscope, blood pressure armband, oxygen, and intravenous bags.
Teams also often carry engagement items to initiate client interactions and meet basic needs, such as food, water, clothing, socks, cigarettes, “mercy beers,” tampons, condoms, and hygiene packs. When it is able to go into the field again, the Mental Health First model intends to use an RV instead of a van, so they can invite clients into the RV for more privacy and then supply them with a variety of supplies for their basic needs (e.g., clothing).
Overall, when deciding the types of uniforms, vehicles, and equipment to obtain, programs considered what would be recognizable, establish expertise, support the service delivery, build trust with those whom they serve, and not trigger or further harm individuals in crisis.
Transport
The ways that programs transport clients to a subsequent location varies in many ways, including when the transport is allowed, who is doing the transport, where clients are transported, and who is affected by the transport decision.
While some programs have the capability to transport clients themselves, others call a third party to do the transport. This depends on whether staff are licensed to do involuntary transports, whether the vehicle is able to transport clients, and whether it is deemed safe to provide transport at that time. Oftentimes, programs will only conduct voluntary transports, and they may pre-establish specific locations or allow the client’s location of choice. If clients do not want to be transported to another location, some programs will end the interaction. Because Denver’s STAR team does not use an ambulance, they can refuse someone’s requested transport to a hospital if a lower level of care is appropriate, such as a sobering center. Some programs conduct involuntary holds, either done by program staff or by calling for police backup. Waiting for police can undermine the level of care provided, a delay which poses a threat to the client’s safety and well-being. Portland’s Street Response program experiences delays of up to an hour when requesting police for involuntary holds; for this reason, the team hopes to have the ability to do 5150 transports themselves, and in a trauma-informed way that gives individuals a sense of control over the situation. Whether a crisis response team can transport clients, initiate involuntary holds, and/or call police for back-up in these situations are all considerations which implicate the continued involvement of law enforcement in crisis response.
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In the transport process, clients may be transported to short- or long-term service providers as well as the client’s location of choice. Some short- term programs include a crisis stabilization facility, detox center, sobering center, homeless shelter, primary care provider, psychiatric facilities, diversion and connection center, hospital, and urgent care. Long-term programs include residential rehabilitation and direct admission to inpatient units of psychiatric emergency departments. Building relationships at these destinations and with providers is key to successful warm handoffs and ensuring clients in crisis receive the appropriate care.
For example, challenges can arise when bringing someone to an emergency room if the hospital is not fully aware of what the crisis response program is, which makes it more difficult to advocate for the client to receive services.
There are many things to consider about client and provider safety when transporting a client. Some programs do not give rides home and only transport the person to a public place. Others have restrictions on when they will transport a client to a private residence. For example, Denver’s STAR team will not take a person home if they are intoxicated and if someone else is in the home because they do not want to put the other person in potential harm. Instead, when responding to an intoxicated individual, the STAR team transports them to a sobering center, detox facility, or similar location of choice. In Portland, first responders and crisis response providers use a risk assessment tool that helps them determine if ambulance transport needs to be arranged. Portland’s risk assessment tool asks providers to determine if the individual has received sedation medication in the last six hours, had a Code Gray in the last 6 hours, had a history of violence and/or aggression, had a history of AWOL, or are showing resistance to hospitalization; if the answer is yes to any of these five questions, then they will arrange for ambulance transport for the individual in crisis.
Follow-up Care & Service Linkage
Follow-up care and linkage to services are handled in a variety of ways.
Some programs include referrals to internal, non-crisis response program staff as a service provided directly by the crisis response team. When community health workers and peer support specialists are staffed on crisis response teams, they often lead the referral and navigation support role. After responding to a crisis, Portland’s Street Response team (an LCSW and paramedic) call a community health worker if the client wants linkages or additional follow-up supports. While referrals and linkages are important to client outcomes and prevention, this kind of follow-up care can be challenging for many programs to do because it can be difficult to find individuals in the community, particularly if they are not stably housed or do not have a working phone. Portland’s Street Response team often goes to encampments to provide follow-up care, which is a program element that is also effective as proactive outreach into local communities.
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Other programs refer individuals to other external teams or organizations not affiliated with the crisis response team whose primary role is to provide follow-up care to individuals who served by the crisis response team.
Olympia’s Crisis Response Unit specifically identifies repeat clients for a referral to a peer navigation program for linkage to care. Additionally, many programs have relationships with community-based organizations and refer clients there for follow-up services. Newer programs that have yet to fully launch stated this was a focus of their program design, as well.
For example, San Francisco’s Street Crisis Response Team partners with a centralized Office of Care Coordination within the San Francisco Department of Public Health that provides clients with linkages to other services; the Street Crisis Response Team essentially embeds this handoff in their own processes.
And, there are some programs that do not include follow-up care within the scope of their services. For example, Eugene’s CAHOOTS program has a narrower focus on crisis stabilization and short-term care; they do not provide referrals or linkage to longer-term services for their clients.
Program Administration
Across the crisis response models that RDA researched and interviewed, there was variability in how they are each administered. As each program is constructed around their local agency structures, resources, needs, and challenges, how their programs are administered are also just as adaptive.
Administrative Structure
The administrative structure and placement of crisis response programs varies significantly. Some programs are administered and delivered by the city/county government, some programs are run in collaboration between a city/county government and community-based organizations (CBO), while others are entirely operated by CBOs.
The administration and structure of a crisis response program may be affected by the geographic and/or population size of the local region and what stage of implementation the program is in. For instance, consistent and guaranteed funding helps sustain programs for the long- term, so developing a program within the local municipal structure may be an advantage over contracting the crisis response program to a CBO.
Some programs found that staff retention was higher for government positions, due to their generally higher wages and increased benefits compared to what CBOs generally offer. Additionally, the use of the existing 911 and dispatch infrastructure may be streamlined for crisis response programs administered by city/county governments because they can be situated within existing emergency response agencies and use existing interagency data sharing and communication processes Attachement 1
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more easily. Finally, programs that are situated within a local health system -- such as Departments of Public Health, Behavioral Health, or public hospitals -- may have existing protocols and processes with which to collaborate with CBOs for referral assistance, case management, resourcing, and follow-up service provision.
On the other hand, programs that are primarily administered and staffed through CBOs reported a sense of flexibility and spontaneity in their program design, expansion, and evolution, especially for early-stage pilots that intend to change and grow over time. These programs shared that they experienced reduced bureaucratic barriers that were conducive to community engagement and program redesign. Additionally, most programs that included peer support specialists in their crisis response program had these roles sourced by CBOs – these peer support specialists were either fully integrated into crisis response teams or were referred to by crisis response teams to provide linkage and follow-up services.
Though there is variety in what entity administers crisis response programs, who sources or contracts the crisis responders, and where funds are generated, all programs require cross-system coordination for designing the program and implementing the dispatch, training, funding, and program evaluation/monitoring activities.
Staffing and sourcing a crisis response program entirely by volunteers can also be helpful in reducing barriers for potential providers to enter this professional field, elevating lived experience of staff, addressing community distrust of the police-involved response system, and building a mental health workforce. However, currently, all-volunteer models face challenges in having consistent and full staffing coverage, which limits a program’s overall service provision and hours of operation.
Financing
Aside from the health benefits of increasing mental health and medical resources in crisis responses, there are financial benefits, too. For example, in Eugene, the CAHOOTS program’s annual budget is $2.1 million. In contrast, the City of Eugene estimates it would cost the Eugene Police Department $8.5 million to serve the volume and type of calls that are directed to CAHOOTS.
13 Several cities are funding crisis response systems through the city’s general fund, which offers a potentially sustainable funding source for the long- term because it demonstrates that city officials are committed to investing in these services with public funds. To generate these funds, Denver added a sales and use tax in 2019 (one-quarter of a percent) to cover mental health services, a portion of which funds the STAR program.
13 White Bird Clinic. (n.d.). What is CAHOOTS?. Retrieved August 29, 2021, from https://whitebirdclinic.org/what-is-cahoots/
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Some cities have funded crisis response programs by reallocating other city funds. Chicago’s Police Department currently pays the salary of the CIT-officer in Chicago’s crisis response pilot program. Chicago’s crisis response pilot also receives additional funding from Chicago’s Department of Public Health. Austin’s EMCOT program is funded by $11 million reallocated from the Police Department. And Eugene’s CAHOOTS program is fully funded through a contract by the Eugene Police Department.
Federal or state dollars have also been used for some crisis response programs. Alameda County’s Community Assessment and Transport Team (CATT) is funding by California’s Mental Health Services Act (MHSA) Innovation funds. Chicago’s current crisis response pilot uses Centers for Disease Control and Prevention (CDC) funding. New York City and Los Angeles both plan to bill Medicaid as a funding source for their emerging crisis response programs. The national Crisis Now program bills per service and per diem for mobile crisis and crisis stabilization services, which is reimbursed by Medicaid.
Some programs are able to leverage private funds to support their services. In addition to the allocation of city funds, Chicago receives funding from foundations and corporations to fund its crisis response program. The Mental Health First program is entirely supported by donations, grants, and volunteer time.
These financing mechanisms provide varying levels of sustainability and predictability, which may affect the longevity of a program and, therefore, its overall impacts. Ensuring that programs can be continuously funded ensures resources go into direct service provision and program administration, rather than on development, fundraising, or grant management. Staff recruitment and retention is also more successful when there is long-term reliability of positions.
Program Evaluation
Many crisis response programs use data to monitor their ongoing progress and successes, modify and expand program pilots, and measure outcomes and impact. Standardizing data collection practices (i.e., data collection tools, measures, values for measures, aligned electronic sources for data entry, etc.) across participating teams and agencies within and across cities/locales, especially for regional plans, supports effective program evaluation and reporting. Addressing this consideration is best done early in program planning because it affects the protocols developed for triage and dispatch, the equipment that crisis response teams use to record service delivery notes or accessing clients’ EHR records, the way referrals and hand-offs are conducted, whether or how Medicaid billing/financing will be leveraged, and more. Several cities noted that they incorporated data sharing and access into MOUs that outlined the scope of work. The providers in most programs have access to an electronic health record (EHR) system that they are able to enter Attachement 1
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their contact notes into – having access to a centralized data collection portal like this can greatly aid a program’s evaluation efforts.
Pilot Program Evaluation Highlight: Denver’s Support Team Assisted Response (STAR) Program
Denver planned to evaluate the STAR program after an initial six- month pilot phase. For the evaluation, data was collected from both the 911 CAD database and the Mental Health Center of Denver. Data was kept in separate systems to protect health- related information from the law enforcement database. The program evaluation provided data on incident locations, response time, response dispatch source (i.e., 911, police unit, or STAR- initiated), social demographics of consumers served, services provided, location of client transport/drop-off, and more. The use of two data systems also allowed the program to evaluate what the STAR team identified as the primary issue of concern compared to clinical diagnoses from the health data.
14 As a result of analyzing these data, Denver identified its program successes and impacts and is committed to expanding the funding and scope of the program. This expansion includes purchasing more vans, staffing more teams, expanding the hours of operation, expanding the service area across the City, hiring a supervisor, and investing in program leadership. Additional plans for future evaluation include building a better understanding of populations served and more rigorous data capture, a longitudinal study to understand consumer long-term outcomes, and a cost- benefit analysis to understand the economic impacts of the program.
Once data is collected, a process for analyzing, visualizing, and reviewing data supports the overall effectiveness of program monitoring, thus contributing to changes to a pilot and the overall outcomes achieved by the program. Some programs have developed internal data dashboards to compile and organize their data in real-time, thus allowing them to review their program data on a weekly basis. And, some programs are also planning for an external evaluation to assist them in developing a broader understanding of their program’s impacts for their clients and in the larger community.
14 Denver STAR Program. (2021, January 8). STAR Program Evaluation. https://www.denverperfect10.com/wp-
content/uploads/2021/01/STAR_Pilot_6_Month_Evaluation_FINAL- REPORT.pdf
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Examples of Metrics that Cities Collect,
Review, and Publish Data On
• Call volume
• Time of calls received
• Service areas
• Response times
• Speed of deployment
• Determinations and dispositions of dispatch
(including specific coding for
violence/weapons/emergency)
• Which teams are deployed across all
emergency response
• Actual level of service needed compared to the
initial determination at the point of dispatch
• Number of involuntary holds that are placed
• Number of transports that are conducted
• Type of referrals made
• Priority needs of clients served (housing, mental
health)
• Frequency of police involvement
Making data about crisis response programs publicly available is also important for community transparency and public research. For example, New York City is planning to publish B-HEARD program data on a monthly basis. And, Portland has a public data dashboard for its crisis response program that is updated at least once per week.15 Such data transparency allows local constituents and stakeholders to check on the progress of their local crisis response program and whether it is making a difference. Such transparency can also contribute to public research and dissemination efforts about emerging alternate crisis response models.
Coordinating the Crisis Response System
Given the complexity of a crisis response system -- from its administrative structure and financing, the technical integration of dispatch with responders, the coordination of referrals and linkages, to client case management -- coordination is an essential, ongoing element of any program. This coordination requires investing in staff time and skills to participate in coordination efforts, focusing on de-siloing all components of crisis response, and effective leadership and vision. Coordination affects financing decisions and contributes directly to client outcomes; therefore, coordination implicates every aspect of program planning, implementation, and evaluation. Overall, program administration benefits
15 Portland Street Response Data Dashboard. (n.d.). City of Portland, Oregon. Retrieved August 29, 2021, from
https://www.portland.gov/streetresponse/data-dashboard
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from having coordination done at a high level, ensuring there is a person(s) responsible for holding the program at a birds-eye view.
Coordinating services between the crisis response team and community partners includes ensuring there are open communication channels between various entities at a structural level down to a client case management level. At a structural level, it requires investing in staff time, technology, and protocol development, not just at the initial program launch but on an ongoing basis. Based on the program evaluation and data collection design, system-level coordination can support ongoing data review and inform future decisions made about a program.
For example, the managers of San Francisco’s Street Crisis Response Team participate in interagency meetings to ensure strategic coordination of service delivery across San Francisco’s Department of Public Health, Fire Department, and Office of Care Coordination. Additionally, when Austin’s EMCOT program’s call center staff integrated the call center technology and co-located their crisis response services within the city’s 911 dispatch, the crisis response program had reduced dropped calls, increased communication around safety and risk assessment during triage, more effective handoffs to mental health clinicians for telehealth, and increased deployment of the crisis response team by dispatch.
System-level coordination also has important downstream effects, such as ensuring that first responders (i.e., police, fire, EMS) can call the crisis response team to respond to a situation if they are dispatched first. At a client level, system coordination can support case management, referrals and linkages, and improved client outcomes. For example, Canada’s REACH Edmonton program provides governance support and
coordination to a network of CBO providers, including facilitating a bimonthly meeting for frontline workers to discuss shared clients. The program shared that for its most complex cases, this coordination significantly increased positive client outcomes. The program also found that they were able to better leverage the expertise of peer support specialists by having a specified coordinator leading these meetings and ensuring their voice and participation was valued. Service providers within this network all utilize the same EHR for documenting and sharing client notes, though the program has encountered challenges in data sharing.
Overall, the REACH Edmonton program shared that system-level coordination must be tightly managed but that most program staff and frontline workers do not have the capacity to do so, so having a centralized governance and coordinating body is essential.
Program Planning Process
Planning the large and small details of a crisis response program is an essential part of a successful launch. Although each city will have a different planning process and timeline based on the local community’s needs and administrative designs, some common themes emerged across the crisis response models that RDA reviewed.
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Planning across city departments typically includes active involvement from emergency medical services, fire, and police as well as leaders from local public health and mental/behavioral health agencies and CBOs.
Many cities stated that having emergency responders involved in the collaborative brainstorming and discussions from the earliest planning stages was essential in garnering buy-in from other city or county departments, including identifying the best resource(s) when responding to mental health needs and crises. Planning also requires engaging other entities; for instance, Portland has to negotiate with the local police union for all services provided by Portland’s Street Response program. Some cities shared that they are aware of beliefs of local police departments and unions about potentially losing funding for police services when new crisis response services are added to the local infrastructure. But, cities found that when they focused the conversation about shared objectives between the crisis response program and the police, police began to see the program as a resource to them as mental health professionals could often better handle mental health crises because of their training and backgrounds. This alignment on shared goals and values underpins the reason that the Eugene Police Department funds the city’s non-police crisis response program, CAHOOTS. Developing a collective and shared narrative around community health and well-being while reducing harm, trauma, and unnecessary use of force, is essential in promoting any crisis response program.
Program planning allows cities to identify elements to include in the pilot that will be investigated throughout the pilot stages. For instance, the planning process may include heat mapping the highest call-volume areas of the city or discussing preliminary milestones to support scaling or expansion of a pilot program. As an example, New York City’s B-HEARD model is currently focused on deploying the B-HEARD team using the existing 911 determination process for identifying mental health emergencies; but, in the future, the program will also assess how those determinations are made to improve the determination and dispatch processes. Their sequencing of planning priorities allowed the program to be launched on a shorter timeline while preparing for an iterative evaluation and design process.
In the future, many learnings can be extrapolated from the ways that crisis response programs are being implemented across the United States and internationally. At this point in time, given that many implementations began within the past two years and are still actively evolving and changing, it is premature to pinpoint common themes in how similar and different jurisdictions and communities (e.g., population size, population density, geography, etc.) are unfolding their emerging crisis response programs.
Planning Timeline
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processes while others launched programs quickly and plan to collect feedback for future iterations of their program.
For instance, Denver had a co-responder model from 2016-2020 and launched the STAR program in 2020 for an initial six-month pilot. The program was launched very quickly in 2020, and then it held community forums to hear from community members for input on the expansion. In Chicago, planning began in the summer of 2019 and the mental health advisory commission developed recommendations in October 2019, then planning and funding continued throughout the summer of 2020, with the program launched in the summer of 2021 (two years after initial program planning began).
New York City’s B-HEARD program was originally announced in November 2020 with an initial launch target of February 2021, though the launch was delayed until June 2021 (eight months later). San Francisco’s Street Crisis Response Team began planning in July 2020 and launched with one team in November 2020 (five months later); the program added a second team and additional hours in January 2021, added four more teams in March 2021, and integrated the local Office of Coordinated Care team for follow-up and linkages in April 2021 (all over a span of four months); the City of San Francisco wanted to move quickly due to its budgeting timeline so it did not conduct much initial community engagement, but rather expected the program design to be an iterative process with future opportunities for community input and evaluation. Additionally, for many pilot crisis response programs, when they are able to scale their services and hire more staff, then they plan to expand their geographical footprints.
Community Engagement
Community engagement is an invaluable element of program design and evaluation that leverages the expertise of the local community members directly impacted by these services. Community engagement activities are conducted to include the perspectives of potential service recipients, existing consumers of the behavioral health and crisis systems, existing coalitions, and/or local community-based service providers in the development and implementation of crisis response programs.
Cities may face barriers in hearing from community members that are the most structurally marginalized, so engaging existing coalitions and networks can support more equitable and targeted outreach. For instance, in Chicago, Sacramento, and Oakland, program planners worked with credible messengers that were connected to networks that the cities were not connected to, such as a teen health council, street outreach teams, homeless advocacy organizations, and disability rights collectives. There was a focus especially on working with mutual aid collectives and other underground groups that do not receive city funding, including voices that may otherwise be neglected in government spaces. This level of outreach and intentionality is essential because, historically, government institutions and other structures have prevented Attachement 1
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the full and meaningful engagement of people of color, working class and cash-poor people, immigrants and undocumented people, people with disabilities, people who are cognitively diverse, LGBTQ+ people, and other structurally marginalized people. Engaging community members that are most directly impacted by crisis response programs, such as unsheltered people, will lead to feedback that is informed by direct lived experiences with the prior and existing programs in a given community.
Additionally, prioritizing the engagement, participation, and recommendations of community members that are most harmed by existing institutions - such as the disproportionate rates of police violence against people of color
16 - will ensure that systems of inequity are not
reproduced by a crisis response program. Instead, intentional community engagement can support the program to address existing structural inequities.
Community engagement can inform program planning, program implementation, and program evaluation in unique ways. When planning for a crisis response program, community engagement can be used to survey existing needs, collect input on priorities, and engage hard-to- reach consumers. To hear directly from community members, Chicago interviewed 100 people across the city to ask about their service needs and how to implement a co-responder or alternative crisis response model. Denver targeted specific community stakeholder groups when collecting feedback for its program design, including perspectives from residents with lived experience, community activists for reimagining policing, a Latinx clinic, and a needle exchange program.
When implementing a crisis response program, engaging the community can identify opportunities for program improvement in real-time and promote community education about the program’s services and partners. To collect feedback on key components of its model, Portland worked with a local university to send a questionnaire to service recipients. Denver prioritized community education by working with Business Improvement Districts (BIDs) to educate them on appropriate and inappropriate times to call 911 and how to more effectively and compassionately engage with unsheltered neighbors. Denver also worked to build trust with local CBOs to increase their engagement of the STAR crisis response team. Such community engagement can improve program implementation by increasing community awareness of the program, clarifying existing barriers for community members, and modifying service provision processes and priorities on an ongoing basis.
16 Edwards, F., Lee, H., & Esposito, M. (2019). Risk of being killed by police use of force in the United States by age, race-ethnicity, and sex.
Proceedings of the National Academy of Sciences of the United States of America (PNAS), 116(34), 16793-16798.
https://www.pnas.org/content/116/34/16793
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Lessons Learned
As cities have begun planning, launching, and iterating on a variety of crisis response program models, they shared key lessons learned and recommendations for new cities considering implementing non-police crisis response programs.
Community members are essential
sources of knowledge.
Program representatives that spoke with RDA emphasized the many considerations that programs must make to ensure a program is utilized and accessible to community members. The interviewed programs emphasized the importance of co-creating programs with community members because community members have experienced the existing crisis response options, know where the gaps exist, and may have already implemented or witnessed community-based short-term solutions that should directly inform program design. Cities explained that creating a program or model that does not appeal to the consumer, especially in terms of the involvement and presence of law enforcement, will decrease Community members are
essential sources of knowledge:
Co-creating a crisis response
model with community members
that have directly experienced
the crisis system will make the
program more accessible and
utilized.
Community engagement requires
time: Build the engagement and
planning time into the overall
program development approach
and timeline.
Use a pilot approach: Test,
modify, and expand specific
aspects of each crisis response
model based on program
successes, challenges, and
consumer feedback.
Build trust across the network:
Cities must build trust across city
agencies and local CBOs to
successfully launch and
implement a crisis response
program.
The 911 dispatch system is
complex: Successful
implementation of a crisis
response program requires
sufficient planning, time/resources
investment, and buy-in for revising
911 call determination and
dispatch processes.
Look to the future: While
alternative models are currently
focused on crisis response, future
models could also support a
population’s holistic health
outcomes and redefine what
“safety” means in a community.
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the reach and impact of the program. Community members must trust the program if they are going to call and engage in services. For example, because they understood that a significant barrier was that the general public was not confident that they could call 911 to engage a non-police response to a mental health or related crisis, the San Francisco’s Street Crisis Response Teams have done significant outreach at community events and presentations at CBOs to build relationships and trust.
Community engagement requires time.
Learning from the community requires time, so plans for community engagement should be part of any new program’s overall timeline and approach. For example, after their initial implementation began, Denver’s STAR teams learned that there is a need to expand their program with multilingual teams, which they have since been effective in making progress towards achieving this. It has been a part of the STAR program’s process to prioritize program needs as they arise while planning for expansion.
Use a pilot approach.
Cities also recommended using a pilot approach so that the model can evolve and expand over time. For example, Chicago piloted two crisis response teams with a CIT-officer and piloted two teams without a CIT- officer to determine the role and efficacy of the CIT-officer in a crisis response. New York City designed their pilot to focus on one zone (a geographic subsection of a borough) before broadening the pilot to more of the city. A pilot approach allows a city to learn from implementation successes and challenges, hear from service recipients, and generate buy-in from potentially hesitant stakeholders.
Build trust across the network.
Cities elevated that building trust across city departments and with CBOs was an essential component of their processes. Cities recognize the different cultures and priorities across city departments and agencies as well as CBOs and volunteers. Within a local government, framing this work as a health response helps to align all partners on their shared values.
Moreover, emphasizing to the local police departments that taking a responsibility off their plate is a benefit to them, which may help them to see the crisis response teams as assets and resources to them.
Additionally, while bringing onboard internal (i.e., city departments and agencies) stakeholders to the table, it is important to ensure that they each have the appropriate degree of weight in decision making for the program. For example, New York City emphasized that law enforcement should not have an imbalance in controlling the conversation or Attachement 1
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decisions. Programs also shared examples of opportunities to build trust across staff members: San Francisco’s Street Crisis Response Team used all- team debriefs to strengthen communication and establish processes; and Canada’s REACH Edmonton used data on their program and outcomes to promote accountability between providers. Ultimately, building and sustaining trust across a network of crisis response teams, first responders, and law enforcement agencies is a type of role that the central coordinating governance structure of a crisis response system should aim to lead and support.
The 911 dispatch system is complex.
The 911 dispatch component of a crisis response model is complex and requires effective collaboration for successful implementation. New York City felt that the dispatch and deployment components of its B-HEARD program took the most time to design well (e.g., diagramming calls, finding existing data), even though the 911 data infrastructure already existed. Similarly, Los Angeles’ Department of Mental Health found the call diversion process and decision-making to be the most challenging aspect to align across departments. By being aware of this hurdle from the beginning, a new program can allocate sufficient time and resources as well as identify strategic personnel to support the development of this important component of any crisis response program.
Look to the future.
Finally, cities offered that they are only in their first steps of a longer process of designing alternative models of care in their communities.
Planning for a program’s next steps can make the initial pilots even more successful and support the transition to future iterations. For instance, Portland’s Street Response program is primarily focused on low-acuity crises, though there is a need for a non-police response that can respond to higher acuity calls, including incidences with weapons, in order to achieve Portland’s aim of reducing police violence. Mental Health First emphasized that an armed officer does not necessarily provide security and safety to bystanders, providers, or consumers, and so alternative crisis response models are countering a larger system of socialization around notions of safety and the role of 911 in a community. Additionally, these models are operating within larger mental health response systems that must work together to ensure fewer community members are going into crisis in the first place. Programs should always be considering how alternative models of care can support individuals from entering into crises, too. Denver’s STAR program shared that they have numerous opportunities for prevention efforts, such as proactive response after encampment sweeps, checking in with consumers in high visibility areas even if there is not a call there, and proactively connecting people to services. By keeping an open mind for what a more holistic crisis response system could look like in their future, cities can plan for their present day, Attachement 1
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early-stage pilot programs to be a part of their evolving and innovative models of care.
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Appendices
Appendix A. SAMHSA’s National Guidelines for
Behavioral Health Crisis Care - Best Practice
Toolkit Executive Summary17
The National Guidelines for Crisis Care – A Best Practice Toolkit advances national guidelines in crisis care within a toolkit that supports program design, development, implementation and continuous quality improvement efforts. It is intended to help mental health authorities, agency administrators, service providers, state and local leaders think through and develop the structure of crisis systems. The toolkit includes distinct sections for:
ü Defining national guidelines in crisis care;
ü Implementing care that aligns with national guidelines; and ü Evaluating alignment of systems to national guidelines.
Given the ever-expanding inclusion of the term “crisis” by entities describing service offerings that do not truly function as no-wrong-door safety net services, we start by defining what crisis services are and what they are not. Crisis services are for anyone, anywhere and anytime. Crisis services include (1) crisis lines accepting all calls and dispatching support based on the assessed need of the caller, (2) mobile crisis teams dispatched to wherever the need is in the community (not hospital emergency departments) and (3) crisis receiving and stabilization facilities that serve everyone that comes through their doors from all referral sources. These services are for anyone, anywhere and anytime.
With non-existent or inadequate crisis care, costs escalate due to an overdependence on restrictive , longer-term hospital stays, hospital readmissions, overuse of law enforcement and human tragedies that result from a lack of access to care. Extremely valuable psychiatric inpatient assets are over- burdened with referrals that might be best-supported with less intrusive, less expensive services and supports. In too many communities, the “crisis system” has been unofficially handed over to law enforcement; sometimes with devastating outcomes. The current approach to crisis care is patchwork and
17 Substance Abuse and Mental Health Services Administration (SAMHSA). (2020). National Guidelines for Behavioral Health Crisis Care – Best Practice Toolkit Executive Summary. https://www.samhsa.gov/find-help/implementing-behavioral-health-crisis-care & https://www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis- services-executive-summary-02242020.pdf
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delivers minimal treatment for some people while others, often those who have not been engaged in care, fall through the cracks; resulting in multiple hospital readmissions, life in the criminal justice system, homelessness, early death and even suicide.
A comprehensive and integrated crisis network is the first line of defense in preventing tragedies of public and patient safety, civil rights, extraordinary and unacceptable loss of lives, and the waste of resources. There is a better way.
Effective crisis care that saves lives and dollars requires a systemic approach.
This toolkit will delineate how to estimate the crisis system resource needs of a community, the number of individuals who can be served within the system, the cost of crisis services, the workforce demands of implementing crisis care and the community-changing impact that can be seen when services are delivered in a manner that aligns with this Best Practice Toolkit. Readers will also learn how this approach harnesses data and technology, draws on the expertise of those with lived experience, and incorporates evidence-based suicide prevention practices.
The following represent the National Guidelines for Crisis Care essential elements within a no- wrong-door integrated crisis system:
1. Regional Crisis Call Center: Regional 24/7 clinically staffed hub/crisis call center that provides crisis intervention capabilities (telephonic, text and chat). Such a service should meet National Suicide Prevention Lifeline (NSPL) standards for risk assessment and engagement of individuals at imminent risk of suicide and offer quality coordination of crisis care in real-time;
2. Crisis Mobile Team Response: Mobile crisis teams available to reach any person in the service area in his or her home, workplace, or any other community-based location of the individual in crisis in a timely manner; and
3. Crisis Receiving and Stabilization Facilities: Crisis stabilization facilities providing short-term (under 24 hours) observation and crisis stabilization services to all referrals in a home-like, non-hospital environment.
In addition to the essential structural or programmatic elements of a crisis system, the following list of essential qualities must be “baked into” comprehensive crisis systems:
1. Addressing recovery needs, significant use of peers, and trauma-informed care;
2. “Suicide safer” care;
3. Safety and security for staff and those in crisis; and Core Services and Best
Practices
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4. Law enforcement and emergency medical services collaboration.
Regional, 24/7, clinically staffed call hub/crisis call centers provide telephonic crisis intervention services to all callers, meet National Suicide Prevention Lifeline (NSPL) operational standards regarding suicide risk assessment and engagement and offer quality coordination of crisis care in real-time. Ideally, these programs will also offer text and chat options to better engage entire communities in care. Mental health, substance use and suicide prevention lines must be equipped to take all calls with expertise in delivering telephonic intervention services, triaging the call to assess for additional needs and coordinating connections to additional support based on the assessment of the team and the preferences of the caller.
Minimum Expectations to Operate a Regional Crisis Call Service
1. Operate every moment of every day (24/7/365);
2. Be staffed with clinicians overseeing clinical triage and other trained team members to respond to all calls received;
3. Answer every call or coordinate overflow coverage with a resource that also meets all of the minimum crisis call center expectations defined in this toolkit;
4. Assess risk of suicide in a manner that meets NSPL standards and danger to others within each call;
5. Coordinate connections to crisis mobile team services in the region; and
6. Connect individuals to facility-based care through warm hand-offs and coordination of transportation as needed.
Best Practices to Operate Regional Crisis Call Center
To fully align with best practice guidelines, centers must meet the minimum expectations and:
1. Incorporate Caller ID functioning;
2. Implement GPS-enabled technology in collaboration with partner crisis mobile teams to more efficiently dispatch care to those in need;
3. Utilize real-time regional bed registry technology to support efficient connection to needed resources; and
4. Schedule outpatient follow-up appointments in a manner synonymous with a warm handoff to support connection to ongoing care following a crisis episode.
To align with National Suicide Prevention Lifeline (NSPL) operational standards, centers must:
1. Practice active engagement with callers and make efforts to establish sufficient rapport so as to promote the caller’s collaboration in securing his/her own safety;
Regional Crisis Call Hub Services – Someone To Talk To
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2. Use the least invasive intervention and consider involuntary emergency interventions as a last resort, except for in circumstances as described below;
3. Initiate life-saving services for attempts in progress – in accordance with guidelines that do not require the individual’s consent to initiate medically necessary rescue services;
4. Initiate active rescue to secure the immediate safety of the individual at risk if the caller remains unwilling and/or unable to take action to prevent his/her suicide and remains at imminent risk;
5. Practice active engagement with persons calling on behalf of someone else (“third-party callers”) towards determining the least invasive, most collaborative actions to best ensure the safety of the person at risk;
6. Have supervisory staff available during all hours of operations for timely consultation in determining the most appropriate intervention for any individual who may be at imminent risk of suicide; and
7. Maintain caller ID or other method of identifying the caller’s location that is readily accessible to staff.
True regional crisis call center hub services that offer air traffic control-type functioning are essential to the success of a crisis system. Cracks within a system of care widen when individuals experience interminable delays in access to services which are often based on an absence of:
1. Real-time coordination of crisis and outgoing services; and
2. Linked, flexible services specific to crisis response; namely mobile crisis teams and crisis stabilization facilities.
Mobile crisis team services offering community-based intervention to individuals in need wherever they are; including at home, work, or anywhere else in the community where the person is experiencing a crisis. For safety and optimal engagement, two person teams should be put in place to support emergency department and justice system diversion. EMS services should be aware and partner as warranted.
Minimum Expectations to Operate a Mobile Crisis Team Services
1. Include a licensed and/or credentialed clinician capable to assessing the needs of individuals within the region of operation;
2. Respond where the person is (home, work, park, etc.) and not restrict services to select locations within the region or particular days/times; and
3. Connect to facility-based care as needed through warm hand-offs and coordinating transportation when and only if situations warrants transition to other locations.
Best Practices to Operate Mobile Crisis Team Services
To fully align with best practice guidelines, teams must meet the minimum expectations and:
Mobile Crisis Team Services – Someone To Respond
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1. Incorporate peers within the mobile crisis team;
2. Respond without law enforcement accompaniment unless special circumstances warrant inclusion in order to support true justice system diversion;
3. Implement real-time GPS technology in partnership with the region’s crisis call center hub to support efficient connection to needed resources and tracking of engagement; and
4. Schedule outpatient follow-up appointments in a manner synonymous with a warm handoff in order to support connection to ongoing care.
Essential functions of mobile crisis services include:
• Triage/screening, including explicit screening for suicidality; • Assessment;
• De-escalation/resolution;
• Peer support;
• Coordination with medical and behavioral health services; and • Crisis planning and follow-up.
Crisis receiving and stabilization services offer the community a no-wrong-door access to mental health and substance use care; operating much like a hospital emergency department that accepts all walk-ins, ambulance, fire and police drop-offs. The need to say yes to mental health crisis referrals, including working with persons of varying ages (as allowed by facility license) and clinical conditions (such as serious emotional disturbance, serious mental illness, intellectual and developmental disabilities), regardless of acuity, informs program staffing, physical space, structure and use of chairs or recliners in lieu of beds that offer far less capacity or flexibility within a given space. It is important to fund these facility-based programs so they can deliver on the commitment of never rejecting a first responder or walk-in referral in order to realize actual emergency department and justice system diversion. If an individual’s condition is assessed to require medical attention in a hospital or referral to a dedicated withdrawal management (i.e., referred to more commonly and historically as detoxification) program, it is the responsibility of the crisis receiving and stabilization facility to make those arrangements and not shift that responsibility to the initial referral source (family, first responder or mobile team). Law enforcement is not expected to do the triage or assessment for the crisis system and it is important that those lines never become blurred.
Minimum Expectations to Operate a Crisis Receiving and Stabilization Service
1. Accept all referrals;
2. Not require medical clearance prior to admission but rather assessment and support for medical stability while in the program;
3. Design their services to address mental health and substance use crisis issues;
4. Employ the capacity to assess physical health needs and deliver care for most minor physical health challenges with an identified pathway in Crisis Receiving and Stabilization Services – A Place to Go Attachement 1
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order to transfer the individual to more medically staffed services if needed;
5. Be staffed at all times (24/7/365) with a multidisciplinary team capable of meeting the needs of individuals experiencing all levels of crisis in the community; including:
a. Psychiatrists or psychiatric nurse practitioners (telehealth may be used) b. Nurses
c. Licensed and/or credentialed clinicians capable of completing assessments in the region; and
d. Peers with lived experience similar to the experience of the population served.
6. Offer walk-in and first responder drop-off options;
7. Be structured in a manner that offers capacity to accept all referrals, understanding that facility capacity limitations may result in occasional exceptions when full, with a no rejection policy for first responders;
8. Screen for suicide risk and complete comprehensive suicide risk assessments and planning when clinically indicated; and
9. Screen for violence risk and complete more comprehensive violence risk assessments and planning when clinically indicated.
Best Practices to Operate Crisis Receiving and Stabilization Services To fully align with best practice guidelines, centers must meet the minimum expectations and:
1. Function as a 24 hour or less crisis receiving and stabilization facility;
2. Offer a dedicated first responder drop-off area;
3. Incorporate some form of intensive support beds into a partner program (could be within the services’ own program or within another provider) to support flow for individuals who need additional support;
4. Include beds within the real-time regional bed registry system operated by the crisis call center hub to support efficient connection to needed resources; and
5. Coordinate connection to ongoing care.
The Role of the Psychiatrist/Psychiatric Nurse Practitioner
Psychiatrists and Psychiatric Nurse Practitioners serve as clinical leaders of the multi-disciplinary crisis team. Essential functions include ensuring clinical soundness of crisis services through evaluation of need, continued monitoring of care and crisis service discharge planning.
Best practice crisis care incorporates a set of core principles that must be systematically “baked in” to excellent crisis systems in addition to the core structural elements that are defined as essential for modern crisis systems.
These essential principles and practices are:
1. Addressing Recovery Needs,
Essential Principles for Modern Crisis Care Systems
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2. Significant Role for Peers,
3. Trauma-Informed Care,
4. Zero Suicide/Suicide Safer Care,
5. Safety/Security for Staff and People in Crisis and
6. Crisis Response Partnerships with Law Enforcement, Dispatch, and Emergency Medical Services.
Addressing Recovery Needs
Crisis providers must address the recovery needs of individuals and families to move beyond their mental health and substance use challenges to lead happy, productive and connected lives each and every day.
Implementation Guidance
1. Commit to a no-force-first approach to quality improvement in care that is characterized by engagement and collaboration.
2. Create engaging and supportive environments that are as free of barriers as possible. This should include eliminating Plexiglas from crisis stabilization units and minimal barriers between team members and those being served to support stronger connections.
3. Ensure team members engage individuals in the care process during a crisis.
Communicate clearly regarding all options clearly and offer materials regarding the process in writing in the individual’s preferred language whenever possible.
4. Ask the individual served about their preferences and do what can be done to align actions to those preferences.
5. Help ensure natural supports and personal attendants are also part of the planning team, such as with youth and persons with intellectual and developmental disabilities.
6. Work to convert those with an involuntary commitment to voluntary so they are invested in their own recovery.
Significant Role for Peers
A transformative element of recovery-oriented care is to fully engage the experience, capabilities and compassion of people who have experienced mental health crises. Including individuals with lived mental health and substance use disorder experience (peers) as core members of a crisis team supports engagement efforts through the unique power of bonding over common experiences while adding the benefits of the peer modeling that recovery is possible.
Implementation Guidance
1. Hire credentialed peers with lived experience that reflect the characteristics of the community served as much as possible. Peers should be hired with attention to common characteristics such as gender, race, primary language, ethnicity, religion, veteran status, lived experiences and age.
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2. Develop support and supervision that aligns with the needs of your program’s team members.
3. Emphasize engagement as a fundamental pillar of care that includes peers as a vital part of a crisis program’s service delivery system. This should include (1) integrating peers within available crisis line operations, (2) having peers serve as one of two mobile team members and (3) ensuring a peer is one of the first individuals to greet an individual admitted to a crisis stabilization facility.
Trauma-Informed Care
The great majority of individuals served in mental health and substance use services have experienced significant interpersonal trauma. Mental health crises and suicidality often are rooted in trauma. These crises are compounded when crisis care involves loss of freedom, noisy and crowded environments and/or the use of force. These situations can actually re-traumatize individuals at the worst possible time, leading to worsened symptoms and a genuine reluctance to seek help in the future.
On the other hand, environments and treatment approaches that are safe and calm can facilitate healing. Thus, we find that trauma-informed care is an essential element of crisis treatment. In 2014, SAMHSA set the following guiding principles for trauma-informed care:
1. Safety;
2. Trustworthiness and transparency;
3. Peer support and mutual self-help;
4. Collaboration and mutuality;
5. Empowerment, voice and choice; and
6. Ensuring cultural, historical and gender considerations inform the care provided.
Trauma-informed systems of care ensure these practices are integrated into service delivery. Developing and maintaining a healthy environment of care also requires support for staff, who may have experienced trauma themselves.
Implementation Guidance
1. Incorporate trauma-informed care training into each team member’s new employee orientation with refreshers delivered as needed.
2. Apply assessment tools that evaluate the level of trauma experienced by the individuals served by the crisis program and create action steps based on those assessments.
Zero Suicide/Suicide Safer Care
Two transformational commitments must be made by every crisis provider in the nation: (1) adoption of suicide prevention as a core responsibility, and (2) commitment to dramatic reductions in suicide among people under care. These changes were adopted and advanced in the revised National Strategy for Suicide Attachement 1
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Prevention (2012), specifically via a new Goal 8: “Promote suicide prevention as a core component of health care services” (p. 51).
The following key elements of Zero Suicide or Suicide Safer Care are all applicable to crisis care:
1. Leadership-driven, safety-oriented culture committed to dramatically reducing suicide among people under care, that includes survivors of suicide attempts and suicide loss in leadership and planning roles;
2. Developing a competent, confident, and caring workforce;
3. Systematically identifying and assessing suicide risk among people receiving care;
4. Ensuring every individual has a pathway to care that is both timely and adequate to meet his or her needs and includes collaborative safety planning and a reduction in access to lethal means;
5. Using effective, evidence-based treatments that directly target suicidal thoughts and behaviors;
6. Providing continuous contact and support; especially after acute care; and
7. Applying a data-driven quality improvement approach to inform system changes that will lead to improved patient outcomes and better care for those at risk.
Safety/Security for Staff and People in Crisis
Safety for both individuals served and staff is a foundational element for all crisis service settings. Crisis settings are also on the front lines of assessing and managing suicidality and possibly violent thoughts or aggressive behaviors, issues with life and death consequences. While ensuring safety for people using crisis services is paramount, the safety for staff cannot be compromised. Keys to safety and security in crisis delivery settings include:
• Evidence-based and trauma-informed crisis training for all staff; • Role-specific staff training and appropriate staffing ratios to number of clients being served;
• A non-institutional and welcoming physical space and environment for persons in crisis, rather than Plexiglas “fishbowl” observation rooms and keypad-locked doors. This space must also be anti-ligature sensitive and contain safe rooms for people for whom violence may be imminent; • Established policies and procedures emphasizing “no force first” prior to implementation of safe physical restraint or seclusion procedures; • Pre-established criteria for crisis system entry;
• Strong relationships with law enforcement and first responders; and • Policies that include the roles of clinical staff (and law enforcement if needed) for management of incidents of behavior that places others at risk.
Providers must establish environments that are safe for those they serve as well as their own team members who are charged with delivering high quality crisis care that aligns with best practice guidelines. The keys to safety and security for Attachement 1
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home visits by mental health staff include:
• No mental health crisis outreach worker will be required to conduct home visits alone.
• Employers will equip mental health workers who engage in home visits with a communication device.
• Mental health workers dispatched on crisis outreach visits will have prompt access to any information available on history of dangerousness or potential dangerousness of the client they are visiting.
Implementation Guidance
1. Commit to a no-force-first approach to care.
2. Monitor, report and review all incidents of seclusion and restraint with the goal of minimizing the use of these interventions.
3. Remember that barriers do not equal safety. The key to safety is engagement and empowerment of the individual served while in crisis.
4. Offer enough space in the physical environment to meet the needs of the population served. A lack of space can elevate anxiety for all.
5. Incorporate quiet spaces into your crisis facility for those who would benefit from time away from the milieu of the main stabilization area.
6. Engage your team members and those you serve in discussions regarding how to enhance safety within the crisis program.
Law Enforcement and Crisis Response—An
Essential Partnership
Law enforcement agencies have reported a significant increase in police contacts with people with mental illness in recent years. Some involvement with mental health crises is inevitable for police. Police officers may (1) provide support in potentially dangerous situations when the need is assessed or (2) make warm hand-offs into crisis care if they happen to be first to engage.
In many communities across the United States, the absence of sufficient and well-integrated mental health crisis care has made local law enforcement the de facto mental health mobile crisis system. This is unacceptable and unsafe. The role of local law enforcement in addressing emergent public safety risk is essential and important. With good mental health crisis care in place, the care team can collaborate with law enforcement in a fashion that will improve both public safety and mental health outcomes. Unfortunately, well-intentioned law enforcement responders to a crisis call can escalate the situation solely based on the presence of police vehicles and armed officers that generate anxiety for far too many individuals in a crisis.
Implementation Guidance
1. Have local crisis providers actively participate in Crisis Intervention Team training or related mental health crisis management training sessions.
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2. Incorporate regular meetings between law enforcement and crisis providers, including EMS and dispatch, into the schedule so these partners can work to continuously improve their practices.
3. Include training on crisis provider and law enforcement partnerships in the training for both partner groups.
4. Share aggregate outcomes data such as numbers served, percentage stabilized and returned to the community and connections to ongoing care.
Psychiatric Advance Directives
A psychiatric or mental health advance directive (PAD) is a legal tool that allows a person with mental illness to state their preferences for treatment in advance of a crisis. They can serve as a way to protect a person's autonomy and ability to self-direct care. Crisis providers are expected to always seek to understand and implement any existing PAD that has been developed by the individual during the evaluation phase and work to ensure the individual discharges from crisis care with an updated and accurate psychiatric advance directive whenever possible. PAD creates a path to express treatment preferences and identify a representative who is trusted and legally empowered to make healthcare decisions on medications, preferred facilities, and listings of visitors.
The full Crisis Services Best Practice Toolkit document contains specific strategies on how a community can fund each of the core crisis system elements in single and multiple-payer environments. Additionally, recommendations on service coding already being reimbursed by Medicaid in multiple states are made available; including the use of HCPCS code H2011 Crisis Intervention Service per 15 Minutes for mobile crisis services and S9484 Crisis Intervention Mental Health Services per Hour or S9485 Crisis Intervention Mental Health Services per Diem for crisis receiving and stabilization facility services.
Many members of the crisis services delivery team are licensed mental health and substance use professionals operating within the scope of their license and training with supervision delivered in a manner consistent with professional expectations of the licensing board. Licensed professionals are expected to strengthen their skills and knowledge through ongoing CEU and CME professional advancement opportunities focused on improving team members’ ability to deliver crisis care.
Providers also incorporate non-licensed individuals within the service delivery Funding Crisis Care
Training and Supervision
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team; creating the need for additional training and supervision to ensure services are delivered in a manner that advances positive outcomes for those engaged in care. Verification of skills and knowledge of non-professional staff is essential to maintaining service delivery standards within a crisis program; including the incorporation of ongoing supervision with licensed professionals available on site at all times. Supervision and the verification of skills and knowledge shall include, but is not limited to, active engagement strategies, trauma-informed care, addressing recovery needs, suicide-safer care, community resources, psychiatric advance directives and role-specific tasks. tasks.
Crisis services must be designed to serve anyone, anywhere and anytime.
Communities that commit to this approach and dedicate resources to address the community need decrease psychiatric boarding in emergency departments and reduce the demands on the justice system. These two benefits translate into better care, better health outcomes and lower costs to the community. The National Guidelines for Crisis Care – A Best Practice Toolkit delivers a roadmap that can be used to truly make a positive impact to communities across the country.
Conclusion
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Appendix B. Sample Outlines of Types of Scenarios for
Crisis Response Teams
Appendix B-1. County and City of San Francisco’s Crisis Response
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Appendix B-2. County of Los Angeles’ Behavioral Health Crisis Triage
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Appendix C. Crisis Response Programs Researched by RDA – Summary of Key Components
Program Dispatch Types of calls Hours of
operation
Crisis team staff Vehicles Follow-up
process
Albuquerque Community Safety
Department – Albuquerque, NM
911 Mental health, inebriation,
homelessness, addiction
TBD Clinicians or peers TBD TBD
B-HEARD (the Behavioral Health
Emergency Assistance Response
Division) – New York, NY
911
dispatch
Mental health Daily 16
hours per
day
2 EMTs or
paramedics + social
worker
Non-transport
vehicles
Connect with
services if
transported;
heat team does
follow-up
(clinician and
peer for follow-
up connection to
services)
Boston Police Department’s Co-
Responder Program – Boston,
MA
911
dispatch
Mental health crisis Unknown Co-responder
(police + clinician)
Police car Unknown
Crisis Assistance Helping Out On
The Streets (CAHOOTS) –
Eugene, OR
911 calls
dispatched
on radio
Non-emergency calls 24/7 Unlicensed crisis
worker and EMT or
paramedic
3 vans with logo Not currently
part of services
Crisis Assessment & Transport
Team (CATT) – Alameda County,
CA
911
dispatch
Mental health Daily 7am-
12am
Licensed clinician +
EMT, co-responding
with police
Unmarked
vehicles, barrier,
custom locks
and windows,
locked storage
cabinets
Unknown
Community Paramedicine –
California (statewide)
911
dispatch
Non-emergency health and
mental health calls
Unknown Paramedics Unknown Unknown
Crisis Call Diversion Program
(CCD) – Houston, TX
911
dispatch
Non-emergency mental
and behavioral health calls
Daily,
morning and
evening
shifts
Mental health
professional tele-
counselors at 911
call center
N/A Unknown
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Program Dispatch Types of calls Hours of
operation
Crisis team staff Vehicles Follow-up
process
Crisis Now – National model (via
SAMHSA)
Regional
crisis call
hub
Mental health 24/7 Licensed clinician +
behavioral health
specialist
Unmarked van Program staff
follows up to
ensure
connection to a
resource
Crisis Response Pilot – Chicago,
IL
911
dispatch
Mental health M-F 9:30-
5:30
Paramedic, crisis
counselor, CIT
officer, peer
recovery coach
2 vans Unknown
Crisis Response Unit – Olympia,
WA
911 or
alternate
number
Mental health,
homelessness
Daily 7am-
9pm
Nurse + behavioral
health specialist
Van owned by
the City
Repeat clients
get referred to
peer navigation
program
(Familiar Faces)
Cuyahoga County Mobile Crisis
Team – Cuyahoga County, Ohio
National
Suicide
Prevention
Hotline
Mental health 24/7 Licensed clinicians Unknown Unknown
Department of Community
Response – Sacramento, CA
911 or
alternate
number
Mental health,
homelessness, youth and
family crisis, substance use
24/7 Social workers 6 vans CBO partner will
provide
connection to
longer term care
and follow up
services
Department of Community
Solutions and Public Safety –
Ithaca, NY
TBD Non-violent calls TBD Unarmed first
responders
TBD TBD
Downtown Emergency Service
Center (DESC) Mobile Crisis
Team – King County, WA
911
dispatch
Mental health, substance
use
24/7 Mental health
professional
Unknown Unknown
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Crisis Response Models Report | 52
Program Dispatch Types of calls Hours of
operation
Crisis team staff Vehicles Follow-up
process
Expanded Mobile Crisis
Outreach Team (EMCOT) –
Austin, TX
911 or
alternate
number
Mental health 24/7 Field staff: two
person teams of
clinicians
Call center staff:
mental health
professionals
Unmarked
vehicles
Post-crisis
services available
for up to 3
months after
initial contact
Georgia Crisis & Access Line
(GCAL) – Georgia (statewide)
Alternate
number,
app
Non-emergency mental
health, substance use
24/7 Mental health
professionals
Unknown Unknown
Los Angeles County Department
of Mental Health - ACCESS
Center – Los Angeles County, CA
Alternate
number
Mental health 24/7 Unknown Unknown Unknown
Los Angeles County Department
of Mental Health - Co-Response
Program – Los Angeles County,
CA
911
dispatch
Emergency mental health Unknown Co-responder
(police + clinician)
Police car Unknown
Los Angeles County Department
of Mental Health - Psychiatric
Mobile Response Team (PMRT)
– Los Angeles County, CA
Alternate
number
Mental health crises Unknown Psychiatric mobile
response team
Unknown Unknown
Mobile Assistance Community
Responders of Oakland
(MACRO) – Oakland, CA
911
dispatch
Non-emergency calls 24/7 Unlicensed
community member
+ EMT
Vehicle with
radios, mobile
data terminal,
cell phones
Community
Resource
Specialist to
connect to
resources
Mental Health Acute
Assessment
Team (MHAAT) – Sydney,
Australia
Ambulance
Control
Center
Acute mental health crises Unknown Paramedic + mental
health nurse
Ambulance Contacted within
3 days, follow up
with referral
facility
Mental Health First / Anti-Police
Terror Project – Sacramento and
Oakland, CA
Alternate
number,
social
media
Mental health, domestic
violence, substance use
Fri-Sun 7pm-
7am
Peer first
responders
Use personal
vehicles and
meet at the
scene; have an
RV with supplies
Have relationship
with CBOs, staff
work to get folks
into longer term
services
Mental Health Mobile Crisis
Team (MHMCT) – Nova Scotia,
Canada
911
dispatch
Mental health 24/7 Co-responder
(police + clinician)
and telephone
clinician support
Unknown Unknown
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Crisis Response Models Report | 53
Program Dispatch Types of calls Hours of
operation
Crisis team staff Vehicles Follow-up
process
Mobile Crisis Assistance Team
(MCAT) – Indianapolis, IN
911
dispatch
Mental health, substance
use
M-F, not
after hours
or overnight
Co-responder
(police + clinician +
paramedics)
Unknown Conduct follow
up visits to
encourage
connection to
care
Mobile Crisis Rapid Response
Team (MCRRT) – Hamilton,
Ontario, Canada
911
dispatch
Mental health Unknown Co-responder (CIT-
trained police +
clinician)
Police car Unknown
Mobile Emergency Response
Team for Youth (MERTY) –
Santa Cruz, CA
Alternate
number
Mental health calls for
youth
M-F 8am-
5pm
Clinician + family
specialist
Van with
wheelchair lift,
comfortable
chairs, TV,
snacks
Continue to
provide services
until patient
connected with
long-term
services
Mobile Evaluation Team (MET) –
East Oakland, CA
911 or
alternate
number
Mental health Mon-Thurs
8am-3:30pm
Co-responder (1-2
mental health
clinicians + police
officer)
Unmarked
police car
Unknown
Psykiatrisk Akut Mobilitet
(PAM) Unit, the
Psychiatric Emergency Response
Team – Stockholm, Sweden
Alarm
center
Acute risk of suicidal
behavior
Daily 2pm-
2am
2 psychiatric nurses
and ambulance
driver
Ambulance Unknown
Police and Clinician Emergency
Response (PACER) – Australia
(several locations)
Dispatched
by police
Mental health Varies Co-responder
(police + clinician)
Unknown Unknown
Portland Street Response –
Portland, OR
911 or
alternate
number
Low-acuity mental health,
substance use, welfare
checks
M-F 10am-
6pm
EMT and LCSW
dispatched to
scene; 2 CHWs
called in for follow-
up
Van with logo CHWs connect to
services;
partnerships
with CBOs for
outreach in
encampments
REACH 24/7 Crisis Diversion –
Edmonton, Alberta, Canada
Alternate
number
(211)
Non-violent, non-
emergency calls
24/7 2 crisis diversion
workers
Have van to
transport
Connector role
for connection to
long-term
services
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Program Dispatch Types of calls Hours of
operation
Crisis team staff Vehicles Follow-up
process
Seattle Crisis Response Team –
Seattle, WA
911
dispatch
Mental health,
assault/threat/harassment,
suspicious circumstance,
disturbance
Unknown Co-responder (CIT +
clinician)
Unknown Clinicians can
follow up with
clients
Supported Team Assisted
Response (STAR) – Denver, CO
911
dispatch
Mental health,
homelessness, substance
use
M-F 10am-
6pm
Mental health
clinician (SW) +
paramedic
Civilian van with
amber lights,
bucket seats on
each side with
standard front
seat
Can hand off to
case managers
Street Crisis Response Team
(SCRT) – San Francisco, CA
911 calls
dispatched
on radio
Non-emergency mental
health
Daily, 12
hours a day
Social
worker/psychologist
+ paramedic + peer
Van with lights
and sirens,
currently using
old fire
department
vehicles
Office of Care
Coordination
provides linkages
to other services
Street Triage – England (several
locations)
Emergency
dispatch
Mental health Varies Mental health nurse Unknown Unknown Therapeutic Transportation Pilot
Program/Alternative Crisis
Response – Los Angeles City and
County, CA
911
dispatch
Mental health crisis 24/7 Mental health
experts co-respond
or take the lead on
MH calls
Plan to have van
for transports
Level 1 calls will
be referred to
non-crisis follow
up services, folks
can step down
from crisis
receiving to
residential
program
Toronto Crisis Response –
Toronto, Ontario, Canada
TBD Non-violent, non-
emergency calls
TBD Mental health
professionals
TBD TBD
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City of Berkeley
Mental Health Crisis Response Services and
Stakeholder Perspectives Report
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City of Berkeley Mental Health Crisis Response & Perspectives | 2 City of Berkeley
Specialized Care Unit Model Recommendations
City of Berkeley Mental Health Crisis Response and Stakeholder Perspectives Report Sarah F
errell
Caroline de Bie
Sasha Gayle-Schneider
Jamie Dorsey
Nicole Gamache-Kocol
Kevin Wu
This re
port was developed by Resource Development Associates under contract with the City of Berkeley Health, Housing & Community Services Department.
Resource Development Associates, October 2021
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City of Berkeley Mental Health Crisis Response & Perspectives | 3
Table of Contents
Executive Summary 4
Introduction 6
Communitywide Data Collection 7
Overview of Berkeley Crisis Response 11
Stakeholder Feedback 23
Community Aspirations 46
Appendices 51
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City of
Berkeley Mental Health Crisis Response & Perspectives | 4 Executive Summary
The City of Berkeley contracted with Resource Development Associates (RDA) to conduct a feasibility study to inform the development of Specialized Care Unit (SCU) pilot to respond to mental health crises without the involvement of law enforcement. RDA’s feasibility study includes community-informed program design recommendations, a phased implementation plan, and funding considerations. RDA’s first report from this feasibility study was a synthesis of crisis response programs in the United States and internationally. This second report details RDA’s synthesized findings from speaking with and collecting data from a myriad of City of Berkeley and Alameda County agencies, community-based organizations (CBOs), local stakeholders and community leaders, and utilizers of Berkeley’s crisis response services.
This report has two focus areas: 1) describing the City of Berkeley’s current mental health crisis response system, including the roles and responsibilities of the various agencies involved and basic quantitative data about the volume of mental health crisis calls received; and 2) sharing key themes from RDA’s qualitative data collection efforts across the Berkeley community.
Presently, callers experiencing a mental health crisis typically call 911, Mobile Crisis Team (MCT) phone line, or the Alameda County Crisis Support Services phone line. Depending on the assessment of the call, phone or in-person services are deployed. All these points of access could result in a police response.
In Berkeley, while there are a variety of programs and service provided by Berkeley Mental Health, Berkeley Police, Berkeley Fire, and an array of community-based organizations, there is an overall insufficient level of resources to meet the volume and types of mental health crisis needs across the city. Stakeholder participants urged that the concept and definition of a mental health crisis and crisis services be expanded to include the full spectrum of a mental health crisis, including prevention, diversion, intervention, and follow-up. Through this lens, stakeholders identified strengths and challenges of the existing crisis response system, described personal experiences, and shared ideas for a reimagined mental health crisis response system.
Key Themes from
Stakeholder Feedback
Perceptions of the urgent need for a non-police mental
health crisis response in Berkeley
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City of Berkeley Mental Health Crisis Response & Perspectives | 5
Perceptions of varied availability, accessibility, and
quality of crisis response services
Perceptions of insufficient crisis services for substance use emergencies
Perceptions of a need for a variety of crisis transport options
Perceptions of a lack of sites for non-emergency care
Perceptions around supporting the full spectrum of
mental health crisis needs
Perceptions of a need for post-crisis follow-up care
Perceptions of barriers to successful partnerships and
referrals across the mental health service network
Perceptions of needs to integrate data systems and
data sharing to improve services
Perceptions of a need for increased community
education and public awareness of crisis response
options
Participants were asked to share their ideas for alternative approaches to mental health and substance use crises as well as to share community needs for a safe, effective mental health and substance use crisis response. Such perspectives illuminate the perceived gaps in the current system that could be filled by a future SCU. These perspectives are summarized as guiding aspirations for reimagining public safety and designing a response system that promotes the safety, health, and well- being of all Berkeley residents.
Community Aspirations
Stakeholder-identified opportunities to address the root causes that contribute to mental health, homelessness,
and substance use crises
Stakeholder-identified opportunities for centering BIPOC communities in crisis response
Stakeholder-identified opportunities for community
oversight to ensure equitable and transformative crisis care
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City of
Berkeley Mental Health Crisis Response & Perspectives | 6 Introduction
In response to the killing of George Floyd by Minneapolis police in May 2020 and the ensuing protests across the nation for this and many other similar tragedies, a national conversation emerged about how policing can be done differently in local communities. The Berkeley City Council initiated a broad-reaching process to reimagine policing in the City of Berkeley. As part of that process, in July 2020, the Berkeley City Council directed the City Manager to pursue reforms to limit the Berkeley Police Department’s scope of work to “primarily violent and criminal matters.” These reforms included, in part, the development of a Specialized Care Unit (SCU) pilot to respond to mental health crises without the involvement of law enforcement.
To inform the development of an SCU, the City of Berkeley contracted with Resource Development Associates (RDA) to conduct a feasibility study that includes community-informed program design
recommendations, a phased implementation plan, and funding considerations. RDA’s first report from this feasibility study was a synthesized summary of its review of the components of nearly 40 crisis response programs in the United States and internationally. This second report details RDA’s synthesized findings from speaking with and collecting data from a myriad of City of Berkeley and Alameda County agencies, community-based organizations (CBOs), local stakeholders and community leaders, and utilizers of Berkeley’s crisis response services.
With the guidance and support of an SCU Steering Committee (led by the Director of City of Berkeley’s Health, Housing and Community Services Department), RDA conducted a large volume of community and agency outreach and qualitative data collection activities between June-July 2021. The goal of this immense undertaking was to understand the variety of perspectives in the local community regarding how mental health crises are currently being responded to as well as the community’s desires for a different crisis response system that would better serve its populations and needs. The City of Berkeley will be implementing an SCU that consists of a team of providers – that does not include law enforcement representation – who will respond to mental health crisis situations in Berkeley. Given that this is happening, RDA’s data collection focused on obtaining perspectives that could inform the development of Berkeley’s SCU; in contrast, RDA’s data collection was not targeted at understanding the validity or utility of having a SCU in Berkeley.
RDA’s outreach and data collection efforts yielded a large volume of information. In order to ensure this report is accessible to a wide audience - in both the length and breadth of findings - RDA’s analysis of all the information it collected was led by a clear goal of identifying common themes across its many data sources. Additionally, RDA sought to distill all findings into manageable pieces that could be succinctly written about in this report.
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City of
Berkeley Mental Health Crisis Response & Perspectives | 7 of the various agencies involved and basic quantitative data about the volume of services provided; and 2) sharing the common themes from RDA’s qualitative data collection efforts across the Berkeley community. It is important to note upfront that given the limited quantitative data available about Berkeley’s historical mental health crisis response calls – as documented and described in much depth by the Berkeley City Auditor’s study (released in April 2021) entitled “Data Analysis of City of Berkeley’s Police Response”
1 – this report is focused on qualitative data. That data allows for a better understanding of what this set of stakeholders feels about the current crisis system and their hopes for an improved system.
After sharing information about Berkeley’s current mental health crisis response services, this report shares information from RDA’s qualitative data collection activities with local agencies, CBOs, stakeholders, and utilizers of crisis response services.
Communitywide Data Collection
In order to fully understand the current state of the mental health crisis system in the City of Berkeley, RDA engaged a variety of stakeholders in gathering both quantitative and qualitative data. As this is a community- driven process, much of the data collection was through engaging members of the Berkeley community. These methods will be described below.
Note: Please refer to the following section,
What is the current mental
health crisis call volume in Berkeley? for a description of the project’s quantitative methods.
Community Engagement Planning
Process
To bring resident and other stakeholder voices into community planning efforts, RDA worked closely with the SCU Steering Committee 2 to develop a comprehensive, inclusive, and accessible outreach and engagement plan. The goal of this plan was not to reach a group that was “representative” of all Berkeley residents, but rather to hear from those that receive crisis response services, those that call or initiate crisis 1 https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_- _General/Data%20Analysis%20of%20the%20City%20of%20Berkeley's%20Pol ice%20Response.pdf
2 Berkeley Specialized Care Unit Steering Committee members: Colin Arnold, Paul Kealoha Blake, Jeff Buell, Caroline de Bie, Margaret Fine, Maria Moore, Andrea Pritchett, David Sprague, David McPartland, Marc Staton, Lisa Warhuus, and Jamie Works-Wright.
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City of Berkeley Mental Health Crisis Response & Perspectives | 8
response, and those whose voices are commonly omitted from city planning efforts. The plan focused on those who are most marginalized by the current system and are most at risk of harm. These groups include, but are not limited to the following:
● Individuals who are frequently targeted by policing, including:
○ Black and African Americans
○ Native Americans
○ Pacific Islander Americans
○ Latinx Americans
○ Asian Americans
○ SWANA (Southwest Asia and North Africa)
● People who have experienced a mental health crisis
● People experiencing or at risk of homelessness
● People who use substances
● Gay, Lesbian, Bisexual, Queer, Transgender and Non-Binary people ● Seniors and older adults
● Transition age youth (TAY)
● People with disabilities
● Survivors of domestic violence and/or intimate partner violence ● People returning to the community from prison or jail ● Veterans
● Immigrants and undocumented residents
RDA and the steering committee also reached out to a wide range of advocates, service providers, and CBOs. In addition to wanting to understand the current state of crisis services from a provider perspective, one of the objectives for reaching out to these advocacy and community organizations was to leverage their community and client connections to reach the target populations.
Once the target groups were identified, RDA and the SCU Steering Committee developed a specific outreach plan and interview guides for each group. The outreach strategy was designed to maximize accessibility by providing multiple opportunities for engagement. Interview guides
3 were customized to each group but followed the same set of four core questions:
1. People’s experiences with, and perceptions of, the current mental health and substance use related crisis response options;
2. Challenges and strengths of current mental health and substance use related crisis response options;
3. Ideas for an alternative approach to mental health and substance use related crises; and
4. Needs identified by the community for a safe, effective mental health and substance use related crisis response.
3 For an example interview guide, see Appendix A.
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City of Berkeley Mental Health Crisis Response & Perspectives | 9
This set of four questions was also used to create a survey distributed to providers unable to attend focus groups, their clients, other service utilizers, and the broader Berkeley community.
It is important to note that mental health crisis affects everyone. RDA purposefully focused engagement efforts on groups that are most often marginalized and at risk of harm from the current crisis system, but in so doing, was an approach that may not have brought in all voices impacted by mental health crisis. The key themes brought out by stakeholders, therefore, may not be fully representative of the broader Berkeley community. Instead, the key themes reflect the perspective of those most impacted by the current system.
Data Sources
All outreach activities occurred between June and July 2021. RDA engaged the community in a variety of in-person and virtual mediums including interviews, focus groups, shadowing, and surveys. In total, RDA conducted 18 focus groups, 51 individual interviews, 1 full day of shadowing dispatch at BPD, and administered 1 online survey.
The CBOs and community members that were targeted for outreach skewed towards either agencies serving unhoused populations in Berkeley or individuals who were unhoused. This was an intentional strategy to reach a population that is generally underrepresented in community-wide data collection efforts. But, as mentioned above, mental health crises can affect anyone, not just those who are unhoused.
Below is a list of groups that were engaged in interviews or focus groups as part of this process.
Type of Group Organizations/Departments (# individuals) City of
Berkeley &
Alameda
County
1. Berkeley Fire Department
2. Berkeley Fire Department – Mobile Integrated
Paramedic (MIP)
3. Berkeley Mental Health
4. Berkeley Mental Health - Mobile Crisis Team
5. Berkeley Mental Health – Crisis, Assessment, and
Triage (CAT)
6. Berkeley Mental Health - Homeless Full Service
Partnership
7. Berkeley Mental Health – Transitional Outreach
Team (TOT)
8. Berkeley Police Department - Key Informants
9. Berkeley Police Department – Dispatch
10. Berkeley Police Department - Community
Services Bureau
11. Berkeley Police Department - Public Safety
Officers
12. City of Berkeley - Aging Services
13. Alameda County Behavioral Health Care
Services
14. Alameda County Crisis Support Services
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City of
Berkeley Mental Health Crisis Response & Perspectives | 10 Type of Group Organizations/Departments (# individuals) Community-
Based
Organizations
1. Alameda County Network of Mental Health
Clients
2. Alameda County Psychological Association
3. Anti Police-Terror Project
4. BACS - Amber House
5. Berkeley Free Clinic
6. Dorothy Day House
7. Harm Reduction Therapy Center
8. LifeLong Medical Care - Ashby Health Center,
Behavioral Health
9. LifeLong Medical Care - Street Medicine
10. Needle Exchange Emergency Distribution
(NEED)
11. Pacific Center
12. UC Berkeley School of Social Welfare
13. Women’s Daytime Drop-In Center
Service
Utilizers
1. People’s Park
2. Seabreeze encampment
3. Planting Justice
Demographics of Participants of RDA’s
Data Collection Efforts
RDA was able to reach a large demographic of providers, service utilizers, and community members across these engagement efforts. These data collection efforts were not focused on providers of mental health care, substance use disorder care, or insurance companies like Kaiser Permanente or the Alameda Alliance. This was a purposeful decision to gain the insight of those who are outside of the current system of care.
Demographic information was not gathered for City of Berkeley or Alameda County staff.
Overall, RDA received information from more people in the 30-44 range than any other age range. As compared to Berkeley’s overall population, service utilizers and providers who identified as Black or African American were overrepresented in RDA’s data collection efforts. There were far more cisgender participants than transgender participants overall, though a higher proportion of service utilizer respondents were transgender compared to survey respondents and provider respondents. RDA collected feedback from more than double the number of female- identifying participants than male identifying participants. Overall, there were very few genderqueer or nonbinary participants. The most common zip codes of participants were 94710, 94702, 94703, and 94704. For more a more detailed description of participant demographics, see Appendix B .
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City of
Berkeley Mental Health Crisis Response & Perspectives | 11 Impacts of COVID-19 Pandemic on Data
Collection
The COVID-19 pandemic made it challenging for this project to engage with participants for data collection. The rise of the Delta variant in August 2021 further complicated matters. Many non-medical social service providers in Berkeley had suspended or limited their in-person services with clients due to the pandemic, so RDA was unable to connect with clients in-person. Invitations were sent to case managers and group/individual counselors to forward to their clients in hopes of interviewing clients, but this did not prove to be effective. Aside from being unable to connect with participants in-person, many providers were overwhelmed with ongoing COVID-19 emergency response and unable to participate in focus groups or the survey. Eleven agencies were in conversation with RDA but were unable to attend any focus groups or submit a survey, and 34 agencies did not respond to attempts to connect. Despite these challenges, RDA found considerable themes and patterns in the data that was collected for this project and feel strongly that the data and perspectives presented here represent the scope of the issues pertinent to mental health crisis response in the City of Berkeley.
Overview of Berkeley Crisis
Response
What is the current mental health crisis
response system in Berkeley?
To understand where the gaps are in the mental health crisis response system in Berkeley, it is important to understand each component and the surrounding landscape of providers and services. The following section describes the process of a mental health call, key city and county entities involved in the crisis system, and other community-based organizations who provide crisis services. This information was gathered during key informant interviews with city and county staff, CBO provider focus groups, and consulting online materials.
Process of Response to a Mental Health Call4
When someone makes a call for a mental health crisis, they will typically call 911, the Mental Health Division’s Mobile Crisis Team (MCT) phone line, 4 See Appendix C for a flowchart of this process.
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City of
Berkeley Mental Health Crisis Response & Perspectives | 12 or Crisis Support Services of Alameda County. The caller is often a family member, friend, or bystander.
If the call goes to 911, the staff member at Berkeley dispatch receives the call. They use the Emergency Medical Dispatch (EMD) protocols to assess whom to deploy to the scene: fire, police, or an ambulance. When assessing a call for the presence mental health issues, they consider many factors including the possibility of violence against the caller or others, certainty or uncertainty of violence, whether the person is using substances and what type of substance, the coherence of the person’s thoughts or behaviors, and background noises. Callers can specifically request MCT, in which case dispatchers may call MCT on the radio and request an MCT call-back for the caller.
If they determine that services can be delivered over the phone, they can transfer the call to Alameda County Crisis Support Services (CSS). If CSS cannot resolve the crisis, they will send the call back to dispatch for an in- person response. If an in-person response is required, they will transfer the call to the appropriate dispatcher staff. Calls with a potential for violence or criminal activity are transferred to police dispatch. Police can call the Berkeley Mobile Crisis Team (MCT) for backup if it is clear that there is a mental health component to the situation. Calls that involve mental health are sent to police dispatch. Police will then alert the MCT that they are needed on-scene. The police will arrive first to secure the scene, then mobile crisis will provide mental health crisis services while police are still on-scene. If the individual needs to be transported to a secondary location, the police will call for an ambulance. Calls that involve a medical or fire issue are transferred to fire dispatch. If fire staff need to place an involuntary hold on the person, they can call police to place the hold.
If the caller decides to call MCT directly, their call will be sent to a confidential voicemail. An MCT staff member will listen to the voicemail, call the person back, and provide services over the phone. If no further services are required, the call is resolved. If an in-person response is required, MCT will call police dispatch to have police secure the scene.
After MCT calls dispatch, they will travel to the scene of the incident.
Once the scene is secured, MCT provides services and may call an ambulance through dispatch if transport is needed.
If the caller decides to call CSS directly, staff will first attempt to resolve the crisis over the phone. If they are able to de-escalate the crisis over the phone, they will provide referral services to additional resources or, on rare occasions, contact Berkeley Mental Health for follow-up care. If they are unable to resolve the crisis, they will send the call to 911 dispatch.
After the incident, the Berkeley Transitional Outreach Team (TOT) will follow-up with the client to ensure that options for longer term care have been offered. TOT can provide referrals and linkage to long-term services, bridging the gap between a moment of crisis and ongoing mental health care.
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City of
Berkeley Mental Health Crisis Response & Perspectives | 13 City and County Teams that Respond During a Crisis
There are several teams within the City of Berkeley and Alameda County that provide services to someone experiencing a mental health crisis.
These include programs within Berkeley Mental Health, Berkeley Police Department, Berkeley Fire Department, and Alameda County Behavioral Health Care Services. Although, as mentioned later in this report, the community does not see these services as sufficient or linked.
Berkeley Mental Health Crisis Programs:
The City of Berkeley is contracted by Alameda County to deliver mental health services to Berkeley residents. In general, Berkeley Mental Health programs are funded to serve individuals with severe mental health needs who have major impairments in their functioning and are covered by Medi-Cal. However, Crisis Services teams (not including Homeless FSP) can serve any Berkeley resident, regardless of diagnosis or insurance status. It should be noted that residents covered by private insurance are eligible for services through their insurer and are not eligible for most Berkeley Mental Health programs.
The Crisis, Assessment, and Triage (CAT) program is a key access point for a wide range of Berkeley residents to get connected to mental health services. They are a team of clinical staff—licensed clinicians, paraprofessionals, peers, and/or family members—that conduct mental health screenings and assessments, mental health planning/consultation, and linkages to county or community-based care. They are also the official entry point for Berkeley Mental Health’s Homeless Full Service Partnership (HFSP), Adult Full Service Partnership (AFSP), and Comprehensive Community Treatment (CCT) programs. As previously noted, these programs have strict eligibility requirements driven by their funding. Most callers are referred to non-city resources. They offer both remote as well as in-person, walk-in assessments, and linkages to appropriate care. If someone is in crisis, they can suggest or facilitate linkage to 911, MCT, Amber House, or other crisis resources. CAT can also provide limited outreach and transportation services to people experiencing homelessness or people with disabilities who also want to engage in mental health services.
The Mobile Crisis Team (MCT) is a team of licensed clinicians that provide crisis intervention services to people in crisis within the Berkeley city limits.
These services include de-escalation and stabilization for individuals in crisis, consultation to hospital emergency personnel, consultation to police and fire departments, hostage negotiation, and disaster and trauma- related mental health services. When fully staffed, MCT can operate 7 days a week from 11:30am-10pm. Due to persistent staff shortages, MCT is currently unable to operate on Tuesdays or Saturdays. They primarily receive referrals from Berkeley Police Department, Berkeley Fire Department, hospital emergency rooms, and directly from residents. Most calls for MCT are received on the police radio directly from BPD for 5150 evaluations. Calls can also come directly through the MCT voicemail.
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City of
Berkeley Mental Health Crisis Response & Perspectives | 14 one unlicensed peer team member. The function of the TOT team is to offer linkages to appropriate resources and help navigating the system of care after someone has experienced a crisis. TOT assesses the individual’s eligibility for services, including insurance status, before making referrals to care. During the pandemic, their services have been mostly limited to phone calls. Pre-pandemic, they regularly connected with service utilizers after they were discharged from the hospital. Most often, TOT connects people with homeless service provider agencies, the CAT team for connection to BMH programs, case management services at other clinics, or any other community provider that would meet the client’s needs. Due to a recent division restructuring, TOT and CAT have been combined into one unit to allow more community members to access information and referrals provided by TOT.
The Homeless Full Service Partnership (HFSP) is Berkeley Mental Health’s newest program. They are a team of two behavioral health clinicians, two social service specialists, one mental health nurse, one part-time psychiatrist (0.5 FTE), and one clinical supervisor. HFSP serves adults who are homeless or at risk of homelessness and have major functional impairments related to a mental health diagnosis. They provide a wide array of services based on the client’s needs including support applying for benefits, connection to short-term and long-term housing, harm reduction for substance use, and support with physical health needs.
Berkeley Police Department: The Berkeley Police Department (BPD) is made up of patrol teams, Communications Center (i.e., dispatch) staff, other sworn officers, and non-sworn professional personnel. In total, the 2020 budget included 181 sworn officers and 104.2 professional staff. [1] BPD patrol team duties include responding to emergency and non- emergency calls for service or criminal activity, enforcing the law, responding to community needs, and directing traffic. The role of BPD patrol teams in mental health crises is to assess the situation to determine if there is a threat of public safety, assess how volatile the situation is, and secure the scene. Oftentimes, police officers will then provide crisis intervention services themselves, either because MCT is unavailable or the officer believes they can adequately respond with their experience and skillset. Otherwise, they will bring in another service team, such as MCT or Fire/ambulance to provide additional mental health or medical services. Officers may on-view incidents, but primarily receive assignments from the Communications Center. Officers may also coordinate with the other City Departments on some cases. All officers also receive a minimum of eight hours of advanced officer training in de- escalation and crisis intervention per year; and many officers are trained in a full week CIT-training course. The Department continues to assign [1] Berkeley City Auditor. (2021, July 2). Data Analysis of the City of Berkeley
’s Police Response.
https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_- _General/Data%20Analysis%20of%20the%20City%20of%20Berkeley's%20P olice%20Response.pdf
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Berkeley Mental Health Crisis Response & Perspectives | 15 officers to this full week training as staffing allows and course space is available.
BPD’s Communications Center is staffed by dispatchers who handle the following: community calls, records checks, fire dispatching, and police dispatching.
[2] Call takers receive non-emergency and 911 calls, assess the call (including using the emergency medical dispatch (EMD) protocol, enter data into the computer aided dispatch (CAD) system to be dispatched to either police or fire personnel where appropriate. Other calls may be directed to other City Departments or BPD work units. The dispatchers deploy the appropriate response to the scene and maintain radio contact until personnel arrive at the scene.
Other sworn officers in BPD include area coordinators, a bike unit, detectives and traffic enforcement unit, and other sworn non-patrol officers. Area coordinators are situated within the Community Services Bureau and work with patrol officers in their area and seek to address community needs. Officers on the bike unit are assigned to patrol specific areas, where they address public safety issues and other community safety concerns. Detectives follow up on criminal investigations, conduct search warrants and work with the District Attorney’s Office on charging. The traffic enforcement unit responds to traffic related complaints, investigates serious injury and fatal collisions, and analyzes and provides state mandated reporting on collision data. Other sworn, non-patrol officers include special assignments in personnel and training, policy, and police technology.
The remaining staff are non-sworn, professional personnel including community service officers, crime scene technicians, and parking enforcement officers. Community service officers work in jail and as crime scene technicians who collect and document evidence from crime scenes. Parking enforcement officers enforce parking violations and support traffic safety related matters. Many of these functions are also supported by Police Aides and Reserve Police Officers.
Berkeley Fire Department: The Berkeley Fire Department (BFD) is comprised of 7 fire stations, 130 sworn fire suppression personnel and paramedic firefighters.5 BFD provides 24/7 response to emergencies including fires, medical emergencies, and disasters. The department operates 4 24/7 Advanced Life Support ambulances that are primarily responsible for all emergency medical transport within the City of Berkeley to local emergency departments.
[2] Berkeley City Auditor. (2019, April 25). 911 Dispatchers: Understaffing Leads t
o Excessive Overtime and Low Morale.
https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_- _General/Dispatch%20Workload_Fiscal%20Year%202018.pdf
5 City of Berkeley Fire Department. (n.d.). History of the Berkeley Fire Department. Retrieved October 5, 2021, from
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Berkeley Mental Health Crisis Response & Perspectives | 16 BFD also participates in care coordination for high utilizers of services as part of the Community Accessing Resources Effectively (CARE) Team. This team is a multidisciplinary group of practitioners made up of both staff from community organizations as well as City of Berkeley staff. The group is facilitated by the EMS division of the department and aims to connect residents using high amounts of emergency services to more appropriate and/or long-term care options.
During the COVID-19 pandemic, BFD operated a Mobile Integrated Paramedic (MIP) unit for a six-week pilot. The MIP unit provided community paramedicine as a diversion from hospitals during the early days of the pandemic. This team did proactive street outreach in the community to help meet basic needs and provide referrals to community organizations, based primarily on 9-1-1 callers who ended up not seeking care at an Emergency Department.
For people experiencing a mental health crisis, the City of Berkeley contracts with Falck Ambulance, which is also the private provider for emergency medical transport for Alameda County. Falck provides treatment, stabilization, and transports to hospitals, including voluntary and involuntary psychiatric hospitalizations. BFD firefighters can call Falck directly when an individual needs to be transported for mental health issues, although most transport requests are through requests from Mobile Crisis. The current collaboration with Falck began July, 1 2019, and the contract is overseen by BFD.
Alameda County Behavioral Health Care Services Crisis Programs:
Alameda County Behavioral Health Care Services (AC BHCS) operates both crisis and long-term mental health service programs.6 Some key crisis programs include Crisis Support Services, Acute Crisis Care and Evaluation for Systemwide Services, Mobile Crisis Team, Mobile Evaluation Team, and the Community Assessment and Transport Team.
The Alameda County Mobile Crisis Team, Mobile Evaluation Team, and the Community Assessment and Transport Team do not serve the geographic area of the City of Berkeley; despite this, we include brief information about them below to describe the types of mobile crisis services available to the other cities in Alameda County.
Crisis Services Eligible to Berkeley Residents
Crisis Support Services (CSS) is a county contracted program that provides several services for individuals experiencing a mental health crisis , including a 24-hour crisis phone line, text messaging, therapy groups, therapy services for older adults, school-based counseling, grief therapy, 6 Alameda County Behavioral Health Care Services. (n.d.). Acute & Integrated Health Care – Acute & Crisis Services. Retrieved October 5, 2021, from http://www.acbhcs.org/acute-integrated-health-care/acute- crisis-services/
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and community education.7 CSS coordinates closely with mobile crisis teams in Oakland and Alameda County and often refer clients to mobile crisis. They are staffed by trained crisis counselors, both licensed and unlicensed. Most often calls to CSS are direct from someone experiencing a crisis. Berkeley dispatch can transfer calls to CSS for phone support if they deem an in-person response is not required. CSS fields over 40,000 calls annually and spends an average of 25-30 minutes per call.
Acute Crisis Care and Evaluation for Systemwide Services (ACCESS) is the main entry point for Alameda County residents to get connected to acute and longer-term mental health and substance use services. 8 The
phone line is staffed by licensed mental health clinicians and administrators who screen and assess the client’s needs, provide information about available options, and refer to an appropriate service.
Clinicians also screen clients to see if they meet medical necessity criteria for Specialty Mental Health Services (SMHS). Calls that come in after 5pm or on weekends are routed to CSS.
Crisis Services Not Eligible to Berkeley Residents
The Alameda County Mobile Crisis Team responds to mental health crisis calls either in-person or over the phone.9 They are staffed by two licensed clinicians. Calls can come directly to the mobile crisis team, or they can be dispatched by 911 or CSS. The Alameda County Mobile Crisis Team responds in a police co-responder model.
The Mobile Evaluation Team (MET) is a co-responder program; one Oakland police officer and one licensed clinician respond to calls in an unmarked police car. They respond to mental health calls that come through 911 dispatch.
The Community Assessment and Transport Team (CATT) provides community-based crisis intervention, medical clearance, and transport services. Administered through Bonita House, a licensed clinician and an EMT will be dispatched to a scene where the individual needs to be transported to a higher level of care. CATT currently utilizes a police co- responder model.
Other Service Providers in the Mental Health Crisis Response System: In addition to services provided by the City of Berkeley and Alameda County, there is an array of community-based services and other providers within the mental health crisis response system in Alameda
7 Crisis Support Services of Alameda County. (n.d.). 24-Hour Crisis Line.
Retrieved October 5, 2021, from Alameda County Behavioral Health Care Services. (n.d.). Acute & Integrated Health Care – Acute & Crisis Services.
Retrieved October 5, 2021, from http://www.acbhcs.org/acute- integrated-health-care/acute-crisis-services/
8 Alameda County Behavioral Health Care Services. (n.d.). ACCESS program. Retrieved October 5, 2021, from
http://www.acbhcs.org/providers/Access/access.htm
9 In this report, the acronym “MCT” is only used in reference to the City of Berkeley’s Mobile Crisis Team, not Alameda County’s Mobile Crisis Team.
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County. These generally fall into four categories: crisis response providers, crisis stabilization units, drop-in centers, and medical service providers.
The agencies listed below are not meant to be a comprehensive list, rather these were the organizations that were mentioned most frequently by focus group participants, interviewees, and survey respondents. There are many organizations and individuals who contribute to crisis prevention and stabilization by addressing other needs such as housing, substance use, ongoing mental health support, or domestic violence. Though not enumerated in this report, the ecosystem of services in Berkeley and surrounding areas help prevent community members from escalating into crisis.
Crisis Response Providers: Crisis response providers accompany individuals while they are experiencing a crisis, work with the client to de-escalate, and connect them to resources to meet their needs. It should be noted that ongoing mental health service providers, such as therapists or clinical case managers, de-escalate and divert mental health crises every day. In this report, we are focusing on providers who respond to acute crisis situations that are outside of long-term supports. The two key crisis response providers mentioned most often by the community are Mental Health First and UC Berkeley.
Mental Health First is a project of the Anti Police-Terror Project (APTP).
Based in Oakland, this volunteer-run crisis line provides crisis support, de- escalation, mediation, and connection to resources to anyone who calls.
They are available on Friday and Saturday nights, 8pm to 8am, when other crisis services are unavailable. Community members can access services via phone, text, or social media. About half of callers are calling for themselves, while the other half are calls from friends or family members concerned about a loved one. Mental Health First can help people navigate the complicated mental health system and get them connected to services.
When a student is experiencing a mental health crisis on the UC Berkeley campus, UC Police Department (UCPD) are often the ones who arrive on scene. UCPD employs a mix of sworn and non-sworn personnel including 49 police officers, 10 dispatch and records staff, 31 security patrol officers, and 12 professional staff.
10 UCPD police officers are currently the ones
who respond during a mental health crisis. However, the University has publicly stated plans to phase out involvement of police during a crisis and shift to having its Tang Center counselors respond to mental health
10 Berkeley UCPD. (n.d.). Department Demographics. Retrieved October 5, 2021, from https://ucpd.berkeley.edu/department-demographics Attachement 2
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Berkeley Mental Health Crisis Response & Perspectives | 19 calls.11 They are currently in the process of planning and developing a new mental health response team.12
The UC Berkeley Tang Center offers health, mental health, and crisis services to all UC Berkeley students, regardless of insurance. Their staff, which include licensed psychologists, psychiatrists, and psychiatric nurses, respond to urgent mental health concerns.13 They also provide services after a sexual assault or incident of domestic violence and respond to campus crises (e.g., when a student passes away). 14 As of the Fall 2021 semester, students can access these services by calling the Tang Center’s urgent phone or after-hours support lines. But as previously mentioned, UC Berkeley is currently redesigning their crisis response model so students can more easily get connected with Tang Center staff during a crisis.
Crisis Stabilization Units and Psychiatric Facilities
Crisis Stabilization Units and psychiatric facilities provide a safe location for people to de-escalate from crisis, receive psychological support, and get connected with mental health services. There are no crisis stabilization units within the City of Berkeley, so Berkeley residents in crisis are often transported or referred to the facilities noted below.
John George Psychiatric Hospital (JGPH, or John George) is a locked facility where patients can receive short-term psychiatric care from doctors, psychiatrists, and counselors. Once a patient receives medical clearance (i.e., they do not have any acute medical needs), they can be transported to JGPH. John George is the main facility that individuals are transported to when they are under an involuntary hold. Many patients are referred and/or transported by emergency services and mobile crisis teams across the County.
Willow Rock Center operates both a 12-16 bed crisis stabilization unit as well as an inpatient unit for adolescents ages 12-17.15 A team of psychiatrists, nurses, group and individual therapists and counselors provides assessment, counseling, medication administration, group, 11 Public Affairs. (2021, August 18). UC Berkeley to shift comes campus services away from UCPD. Berkeley News.
https://news.berkeley.edu/2021/08/18/uc-berkeley-to-shift-some- campus-services-away-from-ucpd/.
12 Berkeley Business Process Management Office. (n.d.). Mental Health Response. Retrieved October 5, 2021, from
https://bpm.berkeley.edu/projects/active-projects/reimagining-uc- berkeley-campus-and-community-safety-program/mental-health 13 University Health Services. (n.d.). Meet the CAPS Staff. Retrieved October 5, 2021, from https://uhs.berkeley.edu/mental-
health/counseling-and-psychological-services-caps/about-caps/meet- caps-staff
14 University Health Services. (n.d.). Crisis Counseling for Urgent Concerns.
Retrieved October 5, 2021, from
https://uhs.berkeley.edu/counseling/urgent
15 Telecare. (n.d.). Willow Rock Center. Retrieved October 5, 2021, from https://www.telecarecorp.com/willow-rock-center
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Berkeley Mental Health Crisis Response & Perspectives | 20 family, individual therapy, and connections to resources. The locked, inpatient unit is the main transport facility for adolescents under an involuntary hold. Their patients are often referred from Kaiser Permanente, schools, and emergency services. They also accept walk-ins for voluntary services.
Cherry Hill Detoxification Services Program provides services for adults needing to detox from substances.16 Their sobering unit has 50 beds for patients to stay 23 hours or less. The detox unit has 32 beds for patients to stay 4-6 days. Trained staff screen patients, provide medical services and psychological support, and link patients to services to meet their needs before discharge. Both units often get referrals from emergency services but also can accept self-referrals.
Amber House, operated by Bay Area Community Services (BACS), is a 23- hour mental health crisis stabilization unit (CSU) that provides a quiet environment for clients to receive short-term psychological support and have their basic needs met. The team is a clinician, a nurse, a supervisor, and an on-call psychiatrist, who provide voluntary services for people experiencing an acute mental health crisis. Many of their clients are transported or referred by mobile crisis teams, Oakland’s CATT program, and occasionally police. Before a client is discharged, a staff member will provide referrals for long-term mental health care and other resources to meet their needs. Amber House also operates a crisis residential treatment (CRT) program in the same facility (which is Alameda County’s only combined CSU and CRT), providing clients the option for a longer stay.
Drop-In Centers
The City of Berkeley has three drop-in centers for residents: the Berkeley Drop-In Center, Berkeley Wellness Center, and the Women’s Daytime Drop-In Center. While not all sites have specific services for individuals in crisis, they can be an entry point for mental health services.
The Berkeley Drop-In Center is a peer-run, walk-in community center that provides drop-in time, service advocacy, and housing advocacy. 17 Clients can have their basic needs met, find a place to socialize, get connected to benefits, receive a referral for subsidized housing, and get linked to mental health services.
The Berkeley Wellness Center, operated by Bonita House, provides art classes, employment services, connection to benefits, primary care, counseling, case management, and evidence-based support groups for 16 Horizon Services. (n.d.). Cherry Hill Detoxification Program Services.
Retrieved October 5, 2021, from https://www.horizonservices.org/cherry- hill-detoxification
17 City of Berkeley. (n.d.). Berkeley Drop-In Center. Retrieved October 5, 2021, from
https://berkeleycity.networkofcare.org/mh/services/agency.aspx?pid=Be rkeleyDropInCenter_670_2_0
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Berkeley Mental Health Crisis Response & Perspectives | 21 adults with mental health and co-occurring disorders.18 The Berkeley Wellness Center serves as an entry point to recovery and supportive services for people with a broad range of mental health needs and co- occurring conditions.
The Women’s Daytime Drop-In Center (WDDC) provides similar services for homeless women and their children.19 A small team of case managers, managers, and volunteers provide various services including case management, food, groceries, and hygiene kits. Clients can also receive referrals to additional services that are beyond the scope of WDDC.
Medical Service Providers
Because a mental health crisis and substance use crisis can co-occur, medical service providers play an important role in crisis stabilization and prevention. The two medical outreach teams mentioned by the community were Lifelong Street Medicine and Berkeley Free Clinic’s Street Medicine team.
LifeLong Street Medicine is a program contracted by Alameda County Health Care for the Homeless Street Health.
20 Multidisciplinary teams
provide street psychiatry and substance use recovery services for people experiencing homelessness in Berkeley. They can also provide connections to primary care, social services, housing, and other resources.
Berkeley Free Clinic’s Street Medicine team is a volunteer-run collective where volunteers are trained as medics and provide services in the community.
21 Their services include HIV and STI testing and treatment, first aid, vaccinations, hygiene kit distribution, and substance use supplies and training. The teams regularly do proactive outreach to connect to new clients.
What is the current mental health crisis
call volume in Berkeley?
In addition to its deep community engagement process, RDA also reviewed quantitative data on the volume of calls related to mental health issues and who is making those calls. As noted previously, quantitative data from City of Berkeley agencies conducting crisis response (i.e., Mobile Crisis Team, Berkeley Police Department, and Berkeley Fire Department) currently have a variety of limitations. Because 18 Bonita House Inc. (n.d.). Berkeley Wellness Center. Retrieved October 5, 2021, from https://bonitahouse.org/berkeley-creative-wellness-center- cwc/
19 Women’s Daytime Drop-In Center. (n.d.). Women’s Daytime Drop-In Center. Retrieved October 5, 2021, from https://www.womensdropin.org/ 20 Alameda County Health Care for the Homeless. (n.d.). Street Health.
Retrieved October 5, 2021, from https://www.achch.org/street-health.html 21 Berkeley Free Clinic. (n.d.). Street Medicine Team. Retrieved October 5, 2021, from https://www.berkeleyfreeclinic.org/street-medicine-team Attachement 2
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Berkeley Mental Health Crisis Response & Perspectives | 22 of these limitations, RDA suspects that the available data is generally an underrepresentation of the true volume of mental health related calls in Berkeley. Given these limitations, RDA explored the available data for trends that can support the community in building its understanding of who is currently utilizing Berkeley’s crisis services.
It is important to note that the City of Berkeley has contracted with the National Institute of Criminal Justice Reform (NICJR) to lead the City’s current Reimagining Public Safety work. As a part of its current engagement, NICJR collaborated with Bright Research Group (BRG) on a large community engagement effort to better understand the local community’s perspectives across a variety of issues pertaining to public safety in Berkeley. NICJR and BRG shared their findings on July 29, 2021 at Berkeley’s Reimagining Public Safety Task Force (RPSTF) meeting; the slide deck presentation of key findings can be found online.
22 The overarching
findings from this presentation align with RDA’s community-wide data collection efforts.
Key Mental Health Call Volume Trends
• MCT has responded to a declining number of 5150s since 2015, in part due to staff vacancies and the pandemic.
• The most frequent incident types of all 5150 calls to BPD were disturbance, welfare check, mentally ill, and suicide.
• Around 40% of BPD’s welfare check calls included a mental health related facet to the response, followed by around 20% of disturbance calls, and around 10% of calls regarding suspicious circumstances.
• Falck has been contracted to conduct the large majority of 5150 transports in Berkeley, most often taking service utilizers to Alta Bates Medical Center and John George Psychiatric Emergency Services.
• BFD conducted fewer 5150 transports in Berkeley and only took service utilizers to Alta Bates, Oakland Children’s Hospital, and Kaiser Hospital.
• The time required for a 5150 is, in part, determined by geography and the destination of transport.
• Calls for 5150s are most frequent from 10:00am to midnight and least frequent from 2:00am to 8:00am. There are no notable differences in the frequency of calls by day of the week.
For a deeper description of call volume and data, demographics of calls, and methods please see Appendix D
.
22 City of Berkeley’s Reimagining Public Safety Task Force. (2021, July 29).
Berkeley Reimagining Public Safety – Community Engagement Report. https://www.cityofberkeley.info/uploadedFiles/Clerk/Level_3_- _Commissions/CE-presentation-Final.pdf
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Berkeley Mental Health Crisis Response & Perspectives | 23 Stakeholder Feedback
Mental health crises vary in severity along a spectrum. A crisis can present as someone in immediate danger to themselves or others, someone that needs regular support to address their basic needs, or someone that is generally able to manage their needs but needs occasional support to prevent a future crisis. Many stakeholders expressed that in order to effectively address the challenges of the current system, solutions and changes must engage with the nuance and spectrum of mental health crises.
Many stakeholders shared that by broadening our concept or definition of a mental health crisis, we can better design the mental health crisis response system and related services. Stakeholders provided several examples of the nuance and spectrum of mental health crises:
Some forms of crisis are readily visible (such as people presenting to hospitals or experiencing a crisis while in public) while others may be unseen (such as a homeless-but-sheltered individual recovering from intimate partner violence).
Some forms of mental illness or neurodivergence are reported by a bystander as a crisis, but there is not an acute crisis situation and should not result in a forced transport just because of a bystander’s concern.
Some forms of crisis are a result of community members not knowing where to access services even if they are able to identify their needs.
Some forms of emergency service utilization stem from an ongoing unmet need for basic goods and services, such as a high utilizer that regularly presents at the hospital emergency department because they need food.
Overall, there is wide consensus among interviewed stakeholders that the current mental health, substance use, and homelessness crisis systems in Berkeley are under-resourced and unable to meet both the volume of need and the various ways in which crisis presents.
Expectations for different types of crisis responders varied greatly by stakeholder. Stakeholders shared mixed experiences with BPD’s ability to successfully de-escalate situations and respond empathetically to people in crisis, and often attributed the quality of interaction to the traits of an individual officer. Stakeholders often held low expectations for BPD to intervene non-violently and expressed positive perceptions when BPD “didn’t do anything.” On the other hand, stakeholders shared high expectations for other crisis service providers including MCT responders or county case managers. Negative feedback from stakeholders was often because providers were not meeting these high standards. As a result, understanding stakeholder praise and criticism of crisis responders – such as MCT, BPD, and other CBOs – requires understanding stakeholders’ varied expectations.
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City of
Berkeley Mental Health Crisis Response & Perspectives | 24 In discussing their experiences as well as the strengths and challenges of existing crisis response system, interviewed participants and survey respondents also shared ideas for a reimagined mental health crisis response system. The following sections detail key themes that were elevated across stakeholder participants.
Illustrative quotes from survey respondents are included alongside key themes. Due to concerns with anonymity and limitations of data collection, quotes from interviews and focus groups were unable to be included.
Key Themes from
Stakeholder Feedback
Perceptions of an urgent need for a non-police mental
health crisis response in Berkeley
Perceptions of varied availability, accessibility, and
quality of crisis response services
Perceptions of insufficient crisis services for substance use emergencies
Perceptions of a need for a variety of crisis transport options
Perceptions of a lack of sites for non-emergency care
Perceptions around supporting the full spectrum of
mental health crisis needs
Perceptions of a need for post-crisis follow-up care
Perceptions of barriers to successful partnerships and
referrals across the mental health service network
Perceptions of needs to integrate data systems and
data sharing to improve services
Perceptions of a need for increased community
education and public awareness of crisis response
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City of
Berkeley Mental Health Crisis Response & Perspectives | 25 Stakeholder perceptions of the urgent need for a
non-police mental health crisis response in Berkeley.
Overall, there was a strong sense of urgency for a change in the response to mental health crises in Berkeley. Service providers indicated that they routinely use creative interventions and provide services for clients multiple times and consider calling the police a last resort. Service providers shared that if there were an SCU, they would prefer to use a non-police option for crisis response.
Service providers and crisis responders expressed a sense that the current system is “broken,” that they see the same service utilizers on a frequent basis. Providers shared examples of clients unable to access existing services, not engaged in services they are enrolled in, or not willing to receive offered treatment for a variety of reasons. Stakeholders felt that most people need support accessing resources in addition to immediate crisis response or de-escalation. However, they believe the existing crisis response system often relies on police to respond to calls. This is not the specialty of the police, nor are they able to provide a full range of follow- up linkages and referrals to trauma-informed social services.
There is strong consensus across city staff, service providers, service utilizers, and survey respondents that police do not best serve the needs of those who are experiencing a mental health or substance use crisis.
Stakeholders emphasized that a mental health crisis should not be equated with violence, though there is often the misconception that any display of mental illness is violent or a threat to public safety.
Stakeholders shared that there are scenarios in which the presence of police can increase the danger for service utilizers or bystanders. In the context of intimate-partner and domestic violence, there is often a fear of retaliatory violence if the police are called in to respond to the abused partner seeking help. Stakeholders shared examples police presence and visible weapons escalating a mental health crisis, causing an increase in erratic or unpredictable client behavior. Particularly for service utilizers with traumatic histories from interactions with police officers, they felt the presence of police can escalate a crisis or emergency. Service providers shared stories of clients that have suffered through immense psycho-social harm and/or medical complications before reaching out to 911 due to their fear of the police.
Survey respondents and service providers shared the perception that sometimes police think a weapon is present on an individual when it is not, and felt that police use unnecessary violence and force, which overall decreases their sense of safety. Stakeholders felt that this context results in an environment in which they do not call for emergency help because of “My perception is that
mental health issues,
substance use, and
homelessness are
*rampant* in Berkeley -
now more than ever -
and police are simply
not the right people to
deal with these issues.”
- SCU Survey Respondent
“I think a carceral
approach creates more
trauma and fear. I have
been traumatized by
being in jail. I do not
wish to be incarcerated
when all I need is
support.”
- SCU Survey Respondent
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a fear of police, leaving community needs for crisis support unmet. Service providers also elevated that there are ways to disarm someone without using force or weapons which would improve the safety for both service utilizers and providers alike.
For these reasons, Crisis Support Services of Alameda County (CSS) crisis line providers shared that they prepare callers for interactions with the police by telling them what to expect when the police arrive and providing options to keep themselves safe (e.g., stepping outside, double checking that there are no weapons or illicit substances on their person, and closing their front door). However, they did mention that service utilizers using substances or experiencing a break with reality may not be able to follow close directions and are at increased risk of police violence due to the heightened probability of misunderstanding or miscommunication.
Stakeholders shared a few strengths of police involvement in the existing crisis response system. They shared that police may provide a useful resource for people who need documentation of a crime for future legal reference. A police report with these details can later be used in a court setting or provided as proof to an insurer. Additionally, many service providers indicated police presence can protect the safety of crisis responders and bystanders when weapons are present. Some stakeholders elevated that the presence of police can be supportive when community members or service providers are attempting to de- escalate a crisis.
The overwhelming importance and immediacy of changing the mental health crisis response system was emphasized in stakeholders’ references to the violence committed against a woman killed by BPD during a mental health crisis in 2013 and a man shot by BPD during a mental health crisis in 2021. Stakeholders shared that providing a non-police mental health crisis response option could increase the acceptability and accessibility of crisis response by addressing this fear, thereby promoting the safety and well-being of community members and service utilizers.
There were differing perspectives of whether police should have any involvement in crisis response. The expressed perspectives included: there should be no police involvement; police should be called as back-up only if SCU de-escalation efforts were unsuccessful; police should be called as back-up only if the presence of weapons was confirmed; or police should be involved through a co-responder model like MCT.
Stakeholders offered important considerations for police involvement.
Some stakeholders suggested that police should be dressed in plain clothes to avoid their presence further escalating a community member in crisis. Other stakeholders shared that if police are involved in the SCU model of crisis response, then they should be in uniform; they elevated that community members should understand who they are speaking to, given that a police officer can arrest, detain, and/or incarcerate them.
Additionally, because community members expressed that they have the right to identify a police officer’s badge number and last name -- which is particularly important if a community member needs to report any “I desperately needed
help for a friend who
was experiencing a
mental health crisis. She
was adamant that I not
call police because she
is scared of them and
feared that they would
be violent with her.
There were no
alternatives available in
Berkeley. I have
watched police
respond to people in
crisis many times. Some
cops are aware that
their presence can
escalate people. Some
of the cops are
oblivious of how they
impact a situation and
make it worse.”
- SCU Survey Respondent
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City of Berkeley Mental Health Crisis Response & Perspectives | 27
misconduct -- police should be in uniform. Furthermore, stakeholders elevated their fear of being targeted by certain police officers as someone that experiences mental health emergencies and/or someone who uses drugs; for this reason, stakeholders shared that it is important for police to remain in uniform to mitigate the criminalization of mental health crises and drug use and for public awareness.
Stakeholders shared considerations for protecting and enhancing the safety and well-being of crisis responders, service utilizers, and community bystanders alike. The presence of weapons is a primary safety consideration for many stakeholders. Stakeholders reported concerns about determining and dispatching the appropriate intervention team in order to prevent injury or assault to crisis responders, especially when there are weapons present. Many stakeholders also emphasized that the safety of the person in crisis must be protected too.
Stakeholders provided many ideas for how a non-police crisis response system could best support Berkeley residents. Community members and providers suggested a crisis response team include mental health practitioners such as peer workers, therapists, direct patient care specialists, social workers, medical providers and/or psychiatrists. They also suggested several trainings that would support crisis responders to better meet the needs of people in crisis, such as trainings on trauma-informed care, de-escalation, and crisis neutralization. Finally, given the types of crises service providers and service utilizers most often experience, stakeholders elevated specific technical knowledge that crisis responders should be prepared to employ, including basic first aid, domestic-violence crisis response training, and specific knowledge on DSM-5 mental health diagnoses, and co-occurring drug-induced states.
Additional Perspectives from the SCU Survey
“The police response here is among the most
professional that I have seen in any jurisdiction in the nation - yet the bottom line is requiring police to
respond to crisis situations in which they do not have
the requisite training is a disservice to both the
officers and those on the other side of the
response.”
“I don't feel unsafe in the community. My homeless
neighbors are much more unsafe than I am
because they are consistently interacting with
people who hate them, with some bad cops
including the campus cops.”
“There is a huge crisis in our city of homelessness and mental health and the police only ever make things
worse. Sweeps, seizures of possessions, harassment
and intimidation of unhoused residents is all too
common. The violent detention of mentally ill
people seems to be a day to day reality. Heavy
restraints and spit hoods being used in the place of
de-escalation and care. The Berkeley police shot a
man in crisis through the mouth this year and that is
beyond unacceptable!!!”
“I need to know that if I, or someone I love, is
experiencing a mental health crisis that there is a
trained mental health professional that I can call
who will come, without a gun, and that I will receive
care, not a cop, and that I will not end up dead.
Knowing I won't be shot dead by a cop for the
"crime" of living with mental illness, for being poor, or for having a substance use disorder would help me
to feel safe.”
“I have had police
response in an
emergency crisis. It only
made the crisis more
terrifying and
traumatic.”
- SCU Survey Respondent
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City of
Berkeley Mental Health Crisis Response & Perspectives | 28 Stakeholder perceptions of varied availability,
accessibility, and quality of crisis response services
Perceiv
ed Strengths
• MCT provides quality
services
• Positive experiences
with individual BPD
officers
• BFD created a
resource list to better
provide referrals
Perceived Challenges
• Lack of 24/7 crisis
services
• Requiring service
utilizers to keep
appointments
• Slow response times for
MCT due to limited
staffing
• Long waitlists for
services
• Few options for de-
escalation or non-
emergency care
• Poorer quality of
services provided to
people of color and
unsheltered people
Stakeholder Ideas
• Proactively
communicate service
availability & hours of
operation
• Increase 24/7 service
options
• Increase training on
racial justice, cultural
sensitivity, harm
reduction, and de-
escalation
Stake
holders identified a few strengths of the availability, accessibility, and quality of crisis services. Many reported that there is general knowledge of the existing crisis response options in Berkeley. Some providers reported positive experiences with police, and many reported positive experiences with MCT. Another strength shared by stakeholders is that BFD’s ability to refer and link service utilizers to resources has increased since they created a list of CBOs and local programs.
A common challenge elevated by stakeholders is the lack of 24/7 response options. A mental health crisis can happen at any time, but many crisis programs operate during standard business hours. The limited hours of operation of MCT were elevated by stakeholders as a significant challenge that increased the risk of police interaction with service utilizers who call 911 when MCT is not staffed.
Stakeholders frequently mentioned limited MCT staffing as a major barrier to accessing quality crisis response services. For the last two years, two of four crisis staff positions have been vacant. Because MCT responds to calls in pairs, only one team is available to respond at a time. This can result in long wait times if the team is responding to another call. Additionally, if there is a high call volume, MCT will prioritize high acuity calls where someone is showing imminent signs of crisis or distress. The reduction in staffing also led to a reduction in hours. This has caused confusion among providers and service utilizers. Service providers elevated this as a source of uncertainty and distrust that can reduce the likelihood of someone accessing services in the future.
“Berkeley MCT is only
open on weekdays
during certain hours. I
have never had an
incident where I
needed help with a
client coincide with
their open hours.”
- SCU Survey Respondent
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City of
Berkeley Mental Health Crisis Response & Perspectives | 29 Stakeholders believe these challenges and barriers to accessing services or ensuring the availability of services are ultimately challenges to the overall safety and well-being of potential service utilizers, community bystanders, and service providers.
A Berkeley City Auditor’s report in 2019 elevated that the understaffing of the 911 Communications Center has led to staffing levels that cannot meet the call volume and increased call wait times.23 Increased call wait times have negative implications for the safety and well-being of service utilizers and community members, as well as the service providers and crisis responders that are responding to a potentially more advanced state of crisis. Additionally, inadequate staffing levels have caused BPD to rely on overtime spending to fund the Communications Center, which increases the cost of the entity.
There was consensus among participants that many facets of the crisis response system feel understaffed, which can lead to decreased service availability and slower responses. Under-resourcing can create challenges to service availability across the providers and programs throughout Berkeley and Alameda County. Service utilizers and community members reported long waiting lists for permanent supportive housing units, a key stabilizing factor that could reduce the incidence of mental health crises overall. There was also a perception among stakeholders that service utilizers are faced with long waits to access healthcare, case managers, and temporary congregate shelters.
Some CBOs also identified a need for more multilingual services, especially Spanish-speaking providers. They also indicated that a fear of ICE or 911-corroboration with ICE is a barrier for undocumented community members to call 911, especially for undocumented residents that are unhoused. Service providers suggested that more culturally competent services would increase the likelihood of someone seeking services when they are experiencing a crisis.
Stakeholders believe that these challenges to availability and accessibility can reduce the quality of available services. When police must respond to a mental health crisis because it is outside MCT business hours, community members do not feel the response was adequate or of the highest quality. Crisis responders expressed that they frequently provide medical solutions when the service utilizers they encounter have mental health needs and are most affected by broader societal problems.
When MCT is not operating, CSS indicated that they do more de- escalation over the phone prior to calling for police support to prepare 23 Berkeley City Auditor. (2019, April 25). 911 Dispatchers: Understaffing Leads to Excessive Overtime and Low Morale.
https://www.cityofberkeley.info/uploadedFiles/Auditor/Level_3_- _General/Dispatch%20Workload_Fiscal%20Year%202018.pdf
“Mobile Crisis folks are
good. It's just that they
always come with the
cops, and sometimes
they can't come for
many hours because
they're busy.”
- SCU Survey Respondent
“It's a revolving door
(with Santa Rita, John
George, etc.) where
crises are sometimes
averted, but almost no
one is truly healed and
set on a good path of
recovery or even
stability.”
- SCU Survey Respondent
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City of
Berkeley Mental Health Crisis Response & Perspectives | 30 the service utilizer and reduce their risk of harm; however, they shared that phone support may not always be sufficient for every mental health crisis.
Overall, there was consensus among stakeholders that there is a lack of successful linkages and connection to follow-up services beyond John George Psychiatric Hospital. Many participants felt that hospitalization may not be appropriate care for everyone experiencing a mental health crisis. Crisis responders and providers reported service utilizers requesting to not be sent to John George, but that as service providers they do not feel they have other options. For service utilizers, trauma histories can be re- triggered by congregate shelters, psychiatric care or hospitals, and police interactions. Stakeholders elevated a need for increased options for where people can be transported during a crisis.
Finally, there is a perception that the quality of the City’s first responder crisis response services is inhibited by a lack of training that sufficiently addresses harm reduction, racial justice and cultural sensitivity training, and successful de-escalation. Service providers shared examples of clients’ needs not being taken seriously, such as instances of individual EMTs not responding to unsheltered clients and/or clients of color. These examples demonstrate how stigma, dehumanization, and racism decrease quality of services.
Given the constraints of how the existing crisis system is funded and resourced currently, stakeholders elevated that any changes to program hours of operation, locations, staffing, phone numbers, and/or other logistical/programmatic decisions be shared regularly and distributed to the partnership network in order to improve availability, accessibility, and quality of service provision. They felt that the ideal alternative crisis response options would include 24/7 mental health crisis response and should address the desired competencies of harm reduction, racial justice and cultural sensitivity, and de-escalation to increase community safety and promote health and well-being.
Additional Perspectives from the SCU Survey
“They tend to exist in ways that are
the most convenient for the service
providers, not for the person in need.
Mental Health Services don't really
happen outside of their offices. How
can disordered, homeless people be
expected to make and keep
appointments at some unfamiliar
address? The drug epidemic is
complicating things and I have seen
no evidence that this city wants to
commit to rehab on demand which is
what we need. We need to be able
to offer help when it is needed- not
when it is convenient.”
“I’ve been doing outreach work for
more than a year in Berkeley now
and access to mental health crisis
support is almost nonexistent. It is
highly needed as many individuals
are experiencing some level of
mental health issues.”
“… My experience with the police
response has been that the City of
Berkeley crisis team has been
understaffed or not working the day
that I phoned, or my report of the
need for crisis support was minimized,
and it was explained that the person
"wasn't breaking any law." Crisis
doesn't often intersect with law
breaking, nor does an individual
always meet the criteria for a 5150.
There are trained individuals who can
help with this, and police often offer
heavy handed threats of arrest, or
physical violence, in attempt to stop
a behavior.”
“The resources we have
are helpful, but we
need more. We
especially need
affordable housing
units. The mobile street
medicine teams have
been very helpful.
Shelters are ok for some
people, but often
exclude people with
disabilities who need
assistance the most.”
- SCU Survey Respondent
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City of
Berkeley Mental Health Crisis Response & Perspectives | 31 Stakeholder perceptions of insufficient crisis services for substance use emergencies
Perceived Strengths
• EMTs respond well to
substance overdoses
• EMTs are well-trusted
by many unsheltered
communities and
encampments
Perceived Challenges
• Not enough SUD
training for clinicians
providing complex
mental illness care
• High rates of transport
to emergency facilities
for substance use
emergencies
• Infrequent referrals to
substance use
management services
• Too few resources to
meet high volume of
substance use
emergencies and
management needs
Stakeholder Ideas
• Incorporate harm
reduction framework
into all crisis response
• Distribute NARCAN
• Distribute harm
reduction supplies
(e.g., sharps disposal,
clean needles, etc.)
Stakeho
lders explained that mental health crises often include substance use emergencies, but they felt that variety and uniqueness of substance use emergencies is often overlooked and not adequately served in the existing crisis response. Stakeholders described many examples of physical and psychosocial health needs related to substance use that do not involve an overdose. Service providers shared that substance use emergencies and mental health crises are often co-occurring as substance use is common among people with histories of trauma and is used as a form of self-medicating.
Substances can alter someone’s mental state and contribute to or exacerbate what is perceived as a mental illness. Stakeholders elevated that when a person is in distress, providers should assume that something is triggering that distress, be it an event or intoxication. One of the most frequently and emphatically emphasized points by service providers was the need to address mental health and substance use in tandem. “Decriminalization is
key to "illegal" drug use
and harm reduction
methods of dealing
with addiction and
drug use save lives
and alleviate the
stigma.”
- SCU Survey Respondent
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City of
Berkeley Mental Health Crisis Response & Perspectives | 32 In the event of a substance overdose, stakeholders felt that Berkeley EMTs are well-trained, follow protocols, and administer effective treatment for users that have overdosed. Stakeholders reported that EMTs are well- trusted by marginalized substance-using communities, including homeless encampments. Seabreeze encampment residents shared that they avoid calling 911 for any emergencies except to specifically request an EMT during an overdose.
Stakeholders described many challenges to how the system currently addresses substance use emergencies. They felt that the physical health and mental health needs of a service user experiencing a substance use emergency are treated as separate needs. Service providers explained that whichever presents as more immediately pressing often dictates the classification for the call; they felt that this results in inadequate service provision during a crisis.
Community-based providers elevated that when seeking care for clients with complex trauma or chronic mental illness, they are rarely put in contact with a provider that has SUD training. Service providers expressed a need for an integrated approach to substance use emergencies, with providers working together to tend to both the psychological and physical health needs of their clients.
Substance users reported frequent transport to hospitals and sobering centers when emergency providers respond to crises. Interviewed substance users shared that they were only informed of other substance use management options when other case managers shared those options (not emergency services personnel prior to transport).
Stakeholders suggested ways that the current crisis response system could better address the needs of substance use emergencies, including incorporating a Harm Reduction framework into first responder's approach to drug use, distributing Narcan, and distributing harm reduction supplies such as clean needles, pipes, and safe sharps disposal kits.
Additional Perspectives from the SCU Survey
“I am a Nurse Practitioner... Some camps in Berkeley have agreements internally not to call the police on each other. If someone does, there is retaliation, sometimes in the form of lighting the person's tent on fire. This means people do not call 9-11 when there is a mental health emergency. While I
completely understand why the mobile crisis unit has police officers, it is not used as often as it could be because of that fact...Many unhoused folks we meet use meth in part to stay up all night so they will not get raped or robbed during the night.
This is of course not the only reason folks use meth and other drugs--there are mental health issues, addiction, etc. But until people are housed, it is very, very hard for them to cut down or quit, because the risks can outweigh the benefits in their minds.”
“...Offering safe use and drug checking
sites, so we can reduce harm that comes
from unsafe drug use. Creating
accessible, affordable, and temporary
housing for each phase of a person's
recovery from crisis. Ensuring people
have access to food, safe shelters, and
access needs are met.”
“The people with
mental illness should
get treatment. In crisis,
they should be housed
with treatment. those
with substance abuse
should have treatment
available. Being
homeless probably
makes people mentally
ill. I think I would be
mentally ill if homeless.”
- SCU Survey Respondent
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City of
Berkeley Mental Health Crisis Response & Perspectives | 33 Stakeholder perceptions of a need for a variety of
crisis transport options
Perceived Strengths
• Transport is provided
to emergency sites
during medical
emergencies
Perceived Challenges
• High rates of
involuntary transports
(5150s) do not align
with service needs
• Lack of options for
transport to non-
emergency sites
• Ambulances and
emergency services
can be cost-
prohibitive for service
utilizers
Stakeholder Ideas
• Provide voluntary
transport to non-
emergency sites
• Provide services and
supplies during
transport process
Crises
can vary in levels of acuity, and not everyone calling in to report a mental health emergency needs transport to a psychiatric facility, hospital emergency department, or inpatient setting. Both EMTs and police shared that they provide free transport to a medical facility, which is important in the event of medical health emergencies. However, Alameda County has the highest rates of 5150s per capita in California.24 Service providers described full emergency departments and service utilizers not being admitted upon arrival. There are also financial implications for being transported in an ambulance, which providers suggested may deter service utilizers from requesting emergency services.
Stakeholders felt that there are few to no options for service utilizers to request transport to a different, non-medical facility or location.
Stakeholders did provide some examples of CBOs and non-emergency programs that provide transportation to their clients, though they shared that these services are not for the general public and barriers to transportation persist.
Given the need for addressing a variety of transport needs, stakeholders elevated the importance of an SCU team to have the ability to provide voluntary transport services to any secondary location, such as a sobering center or a public location. Service providers and community members suggested that the transport vehicle should have available supplies to provide care during a transport, such as one-off doses of psychiatric medicines, food, and water. There was a shared sense that providing 24 California Department of Health Care Services. (2017, October).
California Involuntary Detentions Data Report; Fiscal Year (FY) 2015-2016. https://www.dhcs.ca.gov/services/MH/Documents/FMORB/FY15- 16_Involuntary_Detentions_Report.pdf
“With all the services
available, as a
firefighter, all we can
really do is take
someone to the ER,
which is not definitive
care for homelessness.
Mobile support of
homeless services
would be a game
changer, much the
way mental health
comes out into the
field.”
- SCU Survey Respondent
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City of Berkeley Mental Health Crisis Response & Perspectives | 34
transport options that meet the mental health needs at varying levels of acuity has important implications for the safety and well-being of crisis responders and service utilizers.
Additional Perspectives from the SCU Survey
“...Another challenge is the lack of options for
people in crisis either hospitalization or nothing
which is very harmful. Another issue are people
who feel terrible but are not exactly in crisis but
because there are not enough mental health
providers they are forgotten or left to their own
devices.”
“I need to know that if I call for help, a
compassionate response will arrive and be able to
take a person to a humane location, respite of
some kind. Not forcing them into a hospital where
they are stripped of agency, but giving them a
place where they can stabilize without adding to
their feeling of trauma and powerlessness.”
Stakeholder perceptions of a lack of sites for non-
emergency care
Perceived Strengths
• Drop-in centers, day
centers, sobering
sites, and respite
centers provide
essential non-
emergency services
Perceived Challenges
• No drop-in site for
mental health
emergencies or crises
in Berkeley
• Too few drop-in sites
for non-emergencies
to meet the volume
of need
• Lack of support for
people released
from a psychiatric
hold
Stakeholder Ideas
• Offering drop-in sites
with counselors and
Peer Specialists, a
phone line, and no
service/time limits
• Offering office hours
and/or relationship-
building opportunities
between the SCU
and service utilizers
Stakeholders shared examples of sites that can support non-emergency care and felt that they are effective for mitigating further crises. These examples include drop-in centers, day centers, sobering sites, and respite centers. Services providers believe that such spaces allow individuals to meet their basic needs – including access to restrooms, showers, clothing, food, and rest – as well as have a safe space for self-regulation and self- soothing. Stakeholders, particularly service providers, feel that these types of resources are essential for harm reduction, crisis intervention, health promotion, and crisis prevention. Stakeholders shared that these sites can be a safe and trusted source for someone to access so that a primary caregiver can have a break, such as a parent that provides an adult child behavioral health support and care. Participants mentioned other CBOs
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City of Berkeley Mental Health Crisis Response & Perspectives | 35
that operate drop-in sites, such as the Women’s Drop-In Center or Berkeley Drop-In Center, but service providers indicated that there is still an unmet need for more sites that serve sub-acute needs. Because there is not a drop-in center for emergencies, service utilizers and community service providers described relying on either 911 or the CSS 24/7 phone line. Similarly, stakeholders felt that the availability of non-emergency drop-in centers for individuals to have non-emergency, indoor downtime is too limited to meet the volume of need. CBO service providers as well as crisis responders described situations of individuals being released from psychiatric holds without adequate support upon their release. They felt that these individuals would greatly benefit from the availability of additional drop-in centers.
Service utilizers and community-based service providers emphasized that it would be useful for the SCU to have an office available for community members to develop relationships with the team, like Aging Services’ Senior Centers. They suggested that a drop-in site could have a social worker or peer counselor to accept and direct phone calls, answer questions, and support those accessing the drop-in site.
Additional Perspectives from the SCU Survey
“…addressing the connection to community in the
long term - spaces for people to gather publicly
without needing to pay money, so we can get to
know our neighbors.”
“… We need wrap- around services, a halfway
house or drop-in center for people being released
from a psychiatric hold, to ease them back into
their lives and connect them with ongoing
services.”
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City of
Berkeley Mental Health Crisis Response & Perspectives | 36 Stakeholder perceptions around supporting the full
spectrum of mental health crisis needs
Perceived Strengths
• Relationship building
is important in crisis
response
Perceived Challenges
• Wages, retention,
and union
agreements may
affect type of staff
on crisis response
team
• Crisis response
lacking sufficient
supplies and
expertise for SUD
treatment, de-
escalation, and
system navigation
• Crisis responders are
not often
representative of
service utilizers
Stakeholder Ideas
• Incorporate
clinicians, social
workers, and peer
counselors on crisis
response team
• Increase
compensation for
Peer Specialists and
non-clinical staff
Stake
holders shared many strengths of crisis responders across a spectrum of non-clinical and clinical background and expertise, emphasizing the importance of empathy and building trusting relationships. For instance, TOT staff received positive feedback across stakeholder groups for their follow-up work post-crisis, especially due to their diverse staff and rigorous training in preparation for field work. Service providers emphasized the importance of Peer Specialists to support service utilizers by reassuring them from their own background of lived experience, especially during transport or if the team applies physical restraints.
Crisis responders and service utilizers shared that the pre-existing relationships paramedics have with community members, particularly those that repeatedly need crisis response services, allows paramedics to deliver better care. Some CBOs have observed similar success when incorporating Nurse Practitioners on their street outreach teams. Overall, stakeholders believe that the ability for the same personnel to be providing crisis response services over an extended period can lead to positive outcomes of relationship building and knowing a client’s background.
However, stakeholders raised some potential challenges that must be considered when deciding how to staff a crisis response team. Crisis responders explained that paramedics often have a higher salary than other crisis responders and their skills can be under-utilized during a mental health crisis. They felt that this could make staffing a crisis response “A response team
targeted at de-
escalation and risk
reduction would be
best; it would be best
staffed by those who
can actually connect
people in need to
resources rather turning
a crisis into a criminal
matter, such as police
do.”
- SCU Survey Respondent
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City of
Berkeley Mental Health Crisis Response & Perspectives | 37 program with paramedics less financially efficient. On the other hand, they shared that other crisis responders, such as peer specialists, can be underpaid for their level of contribution, which they suggested might make retention a challenge. One additional consideration shared by crisis responders is that staff can have different union agreements that restrict the number of hours that can be worked per shift, which would affect the program’s overall staffing model and schedule.
Stakeholders felt that some of the services most important for mental health are not always standard practice among current crisis response teams. The types of clinical services that stakeholders reported as most important for mental health crisis response include prescribing psychiatric medicines, administering single-dose psychiatric medicines, quick identification of a substance overdose and/or the need for Narcan intervention, as well as a nuanced understanding of drug-psychosomatic interactions. The types of non-clinical services that stakeholders reported as most important for mental health crisis response included de- escalation, resource linkages and handoffs, system navigation, providing perspective from providers with shared identities or experiences, building ongoing relationships with frequent utilizers, and overall building trust and rapport with the community.
Given the considerations around the types of needs that various specialties can address during crises, as well as the implications for financial feasibility, stakeholders elevated additional ideas for how to staff crisis response teams. Stakeholders expressed support for a crisis response team with a medical provider (e.g., advanced practice nurses, psychiatric mental health nurse practitioners, EMTs, or paramedics), social workers, and especially peer counselors. Stakeholders expressed that non- clinical staff are equally valuable to clinical staff in a crisis response team, a value which should be reflected in their salaries.
Additional Perspectives from the SCU Survey
“We need a crisis response team with trained
social workers, case managers, and clinicians
trained in de-escalation techniques. This team
should be able to connect people in crisis with
emergency shelter and other services.”
“I do not believe that the police are trained to
respond to the needs of an individual, homeless,
or otherwise, experiencing a crisis. Mental health,
substance use, and homelessness related crisis are
best responded to by someone who has been
trained to work with these issues, or a peer who,
along with a trained professional, can provide
support and most importantly, follow up.”
“I think professionals
who are trained to
resolve these crises
non-violently is key. For
example, social
workers.”
- SCU Survey Respondent
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City of
Berkeley Mental Health Crisis Response & Perspectives | 38 Stakeholder perceptions of a need for post-crisis
follow-up care.
Perceived Strengths
• Positive experiences
with existing referral
services (i.e., TOT
and CAT)
Perceived Challenges
• Existing programs do
not meet the volume
of need
• Difficulty contacting
service utilizers for
follow-up care
• Lack of warm
handoffs to follow-up
providers
• Limited long-term
service availability
• Strict missed
appointment policies
Stakeholder Ideas
• SCU provides follow-
up care
• SCU builds
relationships to
support before,
during, and after a
crisis
• Providers should be
familiar with case
history, triggers, etc.
a
For crisis services provided by the City of Berkeley, the Transitional Outreach Team (TOT) is the primary resource for post-crisis follow-up care.
Service utilizers and community-based service providers elevated many strengths about the TOT team, including their ability to connect service utilizers to longer-term care options and social services when interested.
At the same time, stakeholders uplifted a need for additional follow-up care after a mental health emergency. TOT staff and Berkeley Mental Health leadership described many challenges TOT face in meeting the level of need across the crisis spectrum. The team is not adequately staffed to meet the current demand for their services. TOT is a team of only two staff with limited business hours for providing linkage to care. TOT staff also shared that the service provider that responds during a crisis (i.e., MCT) is not the same provider that makes follow-up connections (i.e., TOT), and that there are many potential providers to provide ongoing, long-term care (e.g., Berkeley Mental Health, Alameda County Behavioral Health, or private providers). They felt that this can create challenges for them to provide successful referrals and handoffs to post-crisis follow-up care, sharing background information on clients, and building trust and establishing rapport.
TOT staff also shared many challenges they face in reaching clients, particularly those leaving an inpatient or emergency facility, such as John George or Alta Bates Hospital. They explained that clients are sometimes discharged prior to their connection with TOT, often outside of TOT’s hours of operation. They find it particularly difficult to connect with service utilizers that do not have a cell phone or a consistent residence, which they explain is common among high-utilizer community members, such as those with severe mental illness or those experiencing homelessness. “I think police officers
already deal with so
much, there's often an
acute need they're
responding to when in
fact these individuals
need long-term care.”
- SCU Survey Respondent
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City of Berkeley Mental Health Crisis Response & Perspectives | 39
In general, many people that experience mental illness or mental health crises require or are recommended to long-term therapy or extended sessions. However, it is the perception of stakeholders that services are primarily devoted to high-acuity and short-term and service utilizers are unable to access long-term therapy. Stakeholders felt that the providers who do offer therapy or counseling are unable to meet the volume of weekly appointment needs of service utilizers due to budget and billing constraints. Therapy is not only a form of post-crisis care but also a pre- crisis prevention tool; service providers suggested brief intervention therapy in non-emergency settings (such as a service utilizer walking in during a crisis) to augment the existing crisis response system.
Outside of Berkeley Mental Health services, there are often strict policies around missing appointments, largely tied to insurance and billing requirements, that result in service disruption or termination for service utilizers. Service providers and service utilizers feel that these strict missed appointment policies are inaccessible to many low-income service utilizers and often result in the discontinuation of services. Stakeholders described some barriers that service utilizers may face in maintaining their appointments, including working more than one job (especially during standard business hours), having a reliable cell phone, having access to a calendar, and/or having a reliable mode of transportation.
The importance of follow-up care was elevated by all stakeholder groups as a priority for the SCU. Service providers argued that there may be benefits to having the same people providing care before, during, and after a mental health crisis, to build relationships, establish trust, and understand an individual service utilizer’s care history, behaviors, triggers, and needs.
Additional Perspectives from the SCU Survey
“I would like for the police to be removed from
crisis services and to have a rapid response
available when I call...I would like for there to be
more connection to services and follow up as part
of the planning. There is often not a resource
available for the person, and living on the streets is
stressful, so repeated contact is essential. It can’t
be a one and done and often would mean an
increase in FSP teams.”
“Alternative trained individuals, such as social
workers or mental health professionals as part of this
time, increased community-based mental health
care services, social and rehabilitative services that
highlight social reintegration, such as Supported
Housing, Supported Employment, and Supported
Education.”
We need clean, safe
shelters for people to
spend the night if
they're homeless
and/or under threat.
Kicking them out of
shelters doesn't make
the problem go
away.
- SCU Survey Respondent
Attachement 2
254
City of
Berkeley Mental Health Crisis Response & Perspectives | 40 Stakeholder perceptions of barriers to successful
partnerships and referrals across the mental health
service network
Perceived Strengths
• Providers know the
referral options
available for their
clients
Perceived Challenges
• Limited coordination
and information
sharing between
providers of shared
clients
• BPD engages with
many high utilizers
but is not connected
to the network of
providers
• Lack of trust and
understanding across
service providers
Stakeholder Ideas
• Engage providers in
discussions on system
improvement
• Increase
collaboration
between cities,
counties, and
providers
• Address systemic
factors of crises
• Increased outreach
and care
coordination of
referrals
There was
consensus among stakeholder groups that the existing mental health and crisis service network is complex, involves many providers, and can be a challenge for both clients and providers to navigate. Across these entities, establishing partnerships and referral pathways can be done informally (such as knowing which organization provides which types of services) or can be formalized (such as holding regular case management meetings for shared clients). Among community-based service providers, interviewees shared that they typically do know the scope of options available to their clients.
In general, stakeholders elevated a perceived lack of coordination between service entities in Berkeley. For example, a single client might receive emergency services from John George or Highland Hospital, but also have a primary care provider, have engaged frequently with the LifeLong Street Medicine Team, and have a case manager at the Women’s Drop-In Center for wraparound services. Stakeholders shared that there is not active collaboration across all these entities or an established infrastructure to facilitate an understanding of all the touch points between providers and a service utilizer. Ultimately, stakeholders feel that this obstructs the visibility of how a service utilizer moves through various points in the system. Some providers explained that they may not share the full case history or behavior details of a client with other service providers initially because they fear the client will be rejected or denied service, particularly for violent behaviors. They feel that this prevents informed and well-placed referrals and service provision.
TOT staff shared that service coordination is lacking between hospitals and TOT for post-crisis follow-up care. To connect with an MCT service “A 24-hour crisis
line/team or at least a
team more available
than currently. Police
and that team should
attend the regular city
coordination meetings
with the current teams
that are doing
outreach.”
- SCU Sur
vey Respondent
Attachement 2
255
City of
Berkeley Mental Health Crisis Response & Perspectives | 41 utilizer at the hospital, TOT explained that they must rely on the discharging facility to contact them and coordinate the release of the shared client. TOT staff reported needing to spend time in hospitals to establish relationships with new case managers, front desk staff, nurses, and orderlies to facilitate this information sharing and warm handoff of clients; they described a lack of standardized protocol for such coordination.
BPD also reported feeling disconnected from the care continuum and lacking coordination with trusted CBOs and behavioral healthcare providers around shared clients. BPD routinely engages with frequent crisis service utilizers and sometimes carries supplies like food and clothing, though there is not an existing pathway for BPD to identify, contact, and coordinate with a case manager. BPD elevated that these frequent utilizers would be better served by a case manager.
Service providers also reported that BPD does not routinely bring service utilizers to their locations for support, and some questioned whether BPD know that their programs and services exist. Still, others felt that police presence at their sites is disruptive and may prevent potential service utilizers from coming if they witness police officers around the premises.
Stakeholders offered possibilities to enhance the referral pathways and partnerships across the crisis response network at both structural and provider levels. At a structural level, stakeholders suggested having a regular convening of local care providers to discuss opportunities to improve the mental health crisis system. Stakeholders also suggested having more inter-county and inter-city coordination on systemic issues related to housing and healthcare. Stakeholders suggested that the crisis response system should be expanded and augmented to include more non-mental health related service provision on the spot and not only connections or linkages to resources. Additionally, stakeholders expressed a desire for more outreach and partnerships with long-term care to enhance coordination and referrals across the service network.
At a provider level, stakeholders suggested having more coordination between providers and outreach teams. Service providers also expressed an interest in having regular meetings with the SCU to discuss shared clients, which could improve care coordination as well as client outcomes.
Additional Perspectives from the SCU Survey
“The challenge is, and has been, to have adequate staffing to provide services to those in crisis, with severe mental health diagnosis and/or dual diagnosis in the moment and following a crisis response.
Successful efforts have been proven by street health teams to engage and provide treatment on the street, which often include de-escalation. The struggle lies on helping folks transition into care in the clinics, recovery programs, or a combination of both: with adequate staffing to provide long term services. So, challenges would fall under budget & funding to expand staffing and programming, including crisis residential, and Board and Care Homes...The City appears open and willing to try an approach that will better meet the needs of its citizens.” Attachement 2
256
City of
Berkeley Mental Health Crisis Response & Perspectives | 42 Stakeholder perceptions of needs to integrate data
system and data sharing to improve services
Perceived Strengths
• Some medical
clinics use the
same EHR
• Some agencies
use a shared
Alameda County
Community
Health Record
Perceived Challenges
• Limited data
integration across
providers inhibits
care coordination
Stakehol der Ideas
• Expand data
integration across
providers and
provider access to
case history
• Increase care
coordination across
providers
• Notify case
managers after
discharge from
hospital
Service
providers feel that better system integration and data sharing across the service provider network can support providers in meeting the needs of service utilizers. Stakeholders feel that system integration and data sharing are strongly related to the successes and challenges of partnerships, referrals, and connectivity across the service network.
The numerous entities that span the mental health, substance use, and homelessness service network include CBOs and government agencies across the City of Berkeley, Alameda County, and other cities and counties. Service utilizers also move across these regions, accessing services in multiple cities or counties. As a result, system integration could happen at many levels.
Fortunately, subsets within the service network do have data integration and sharing capabilities. For instance, providers shared that all federally - qualified health centers (FQHCs) are on the same network as hospital Emergency Departments.
Some program directors also discussed a recent effort at the county level to integrate data into one Community Health Record for service utilizers. 25 This system integrates medical, mental health, housing, and social service data into one platform. There are currently over 30 organizations within 25 Alameda County Care Connect. (n.d.). Why AC Care Connect? Why Now? Retrieved October 11, 2021, from https://accareconnect.org/care- connect/#faq-item-5
“I would also feel safe
knowing that the City
and County were
working together to
identify ways to
increase funding for
mental health services
in conjunction with
housing to meet the
mental
health/substance use
recovery needs of the
community.”
- SCU Su
rvey Respondent
Attachement 2
257
City of Berkeley Mental Health Crisis Response & Perspectives | 43
Alameda County who are using the community health record, with a goal of every agency being onboarded onto the system.26
Until then, the current multitude of agency data systems are not yet fully integrated. Providers explain that they are unable to identify shared clients or high utilizers of multiple systems, track those service utilizers’ touchpoints across the service network, or view patient history across those service touchpoints. Case managers share that they are not notified when a client is discharged from a medical facility or community provider of care. Service providers feel that this lack of data integration affects collaboration, referrals, and, ultimately, client outcomes. The limited visibility of a service utilizer’s prior history was raised by service providers as a challenge to supporting safety when trauma histories, triggers, and recent mental health crises cannot be incorporated into care planning.
Additionally, except for diagnosis and treatment purposes, HIPAA privacy regulations require service utilizers to give consent and Release of Information (ROI) to providers for external case managers’ names, information, and service documentation to be included in medical records. This limits the collaboration between case managers and other providers on a case-by-case basis.
Stakeholders elevated that it would be ideal to have all service providers, including an SCU, utilizing the same data platform. They also indicated that non-medical CBO providers and case managers should have contact with the client’s health home (if established), especially for substance use management and medication management. Case managers could then be notified when a service utilizer is engaged or discharged from care. Service providers emphasized the importance of understanding someone’s medical and social history to provide appropriate care and anticipate what could trigger or escalate them.
Service providers also warned to not overburden the SCU with documentation requirements.
Additional Perspectives from the SCU Survey
“… Secondly, we need significantly greater inter-municipal and inter-county collaboration in order to tackle structural problems that homeless and mentally ill clients face…Increasingly, our clients are more mobile, have longer commutes, and with gentrification and sprawl, landscapes of poverty and wealth are shifting. We need to be able to be responsive to clients across municipalities and communities, as people who seek services in Berkeley, particularly homeless and low -income clients, often no longer have the means themselves to be able to live in Berkeley.”
26 Raths, D. (2021, October 4). Alameda County’s Social Health Information Exchange Expands. Healthcare Innovation.
https://www.hcinnovationgroup.com/interoperability-hie/health- information-exchange-hie/article/21240807/alameda-countys-social- health-information-exchange-expands
“… But we need more
training in mental
health, de-escalation
and interagency
training and
coordination. We
have a lot of great
people working these
issues, we just need a
little more cross
pollination of effort.”
- SCU Survey Respondent
Attachement 2
258
City of Berkeley Mental Health Crisis Response & Perspectives | 44
Stakeholder perceptions of a need for increased
community education and public awareness of crisis
response options
Perceived Strengths
• 911 is well-known by
the general public as
a crisis response
option
Perceived Challenges
• Lack of clarity that
MCT responds with
police, undermining
trust
• Limited knowledge
around services and
availability
• Distrust of system can
prevent people from
calling 911
• Incidents of
unnecessary use of
911
Stakeholder Ideas
• Launch a public
awareness
campaign for new
SCU and clearly
distinguish it from
MCT
• Work with partners
and service providers
to advertise SCU
• Increase community
education on use of
911 and techniques
for conflict resolution
A common perspective among stakeholders is that the general public is unclear around when police will or will not be involved in a response.
Many service providers and service utilizers do not know the current options and availability of services in Berkeley to support during a mental health crisis. Overall, stakeholders share that there is a lack of understanding of what services are available and which entity provides those services. They feel that this undermines a sense of safety and contributes to distrust of the current mental health crisis response system.
One common challenge raised by many stakeholders has been the lack of understanding of MCT’s co-responder model. Many providers shared that they have contacted the MCT line specifically to avoid calling 911 and were surprised when MCT was accompanied by police. Many providers, therefore, stopped calling MCT because of its collaboration with BPD. Similarly, service utilizers shared that there is a lack of trust that MCT can manage a crisis without police presence. Service utilizers are concerned that their safety is endangered in these instances and that they may experience retaliation or police surveillance after requesting service provision from MCT, especially when they request help during substance use emergencies.
Stakeholders spoke to the importance of promoting community education and public awareness to address these challenges. They feel that the success of an SCU would be contingent on community education and public awareness around whether there would be police involvement in an SCU response. Service providers shared that connecting with local CBOs, leveraging existing partnerships, and building trust will be essential for an SCU to have buy-in among service providers to call a new “In the past, I have
witnessed unsafe
situations or people
who look like they
could use support, but I
am too afraid to call
the police in those
situations, for fear that
they could show up
and harm or kill the
person.”
- SCU Survey Respondent
Attachement 2
259
City of Berkeley Mental Health Crisis Response & Perspectives | 45
service that they have not used before. Service providers are interested in understanding more closely how services will be provided, the techniques that will be used for de-escalation and crisis intervention, and the SCU’s relationship with the police.
Stakeholders also shared challenges around the general public’s use of 911 and ideas for how to increase responsible use of 911. Stakeholders shared many instances of inappropriate use of 911, such as during disputes among neighbors or because a housed person or business does not want an unhoused neighbor to be near them. For these reasons, stakeholders emphasized the importance of a community education campaign around appropriate uses of 911. Stakeholders suggested that such a campaign could include strategies and techniques for managing conflicts and disputes without calling for crisis responders as an additional form of promoting community safety through methods that do not require law enforcement.
Additional Perspectives from the SCU Survey
“Merchants in the shopping districts should not be able to call the cops like they're calling customer service when a homeless person is not breaking any laws. It would be great if crisis services were more friendly and less coercive (cops), if the mental health delivery system was more robust, if crisis teams could respond in a timely way, if clinicians didn't use police radios on mobile crisis calls, if actual risk assessments were done on calls where no one would ever need a cop (when the person is willingly ready to go to the hospital), if hospitals would actually keep and treat the most ill patients rather than turning them away after 24 hours in a waiting area, if there were more mental health respite beds run by people who aren't ready to call the police if someone is agitated.”
“More trained & well-
compensated and
insured crisis response
staff, especially at night,
around the full moon, or
public events, & other
times of increased
disturbances, & more
info put out there about
what they do to help.”
- SCU Survey Respondent
Attachement 2