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Wake County Behavioral HealthPlanning SummitCrisis ServicesWednesday March 24, 2021Michael ZarzarDivision Head UNC Psychiatry, Wake CountyMedical Director UNC Health WakeBrook
Crisis ServicesWhat is includedFor Summit Admission to a hospital emergency department or inpatientpsychiatric hospitalAdmission to crisis assessment, facility-based detox or crisis facilityAdmission to any inpatient psychiatric hospitalMobile CrisisEMS response to mental health crisisBehavioral Health Urgent CareBehavioral Health ERRPD/Social Worker response teamCrisis Call Center/988
Behavioral Health Summit 2017 Expand adult crisis assessment service capacity and add additionallocationsAdd adult facility-based crisis bedsExpand Geriatric crisis assessment servicesDevelop a walk-in behavioral health urgent care serviceCreate respite (step-down) for individuals exiting health care facilitiesImprove mobile crisis service modelIncrease size of psychiatric inpatient capacityDevelop a Behavioral Emergency RoomImplement an education campaign to improve awareness of how to accesscrisis servicesObtained from information for 2017 Behavioral Health Summit
Wake County Behavioral Health PlanGoals 2019-2020 Expand capacity of adult crisis assessment service; add additionallocations Develop a behavioral health urgent care service Increase psychiatric inpatient capacity Increase community outpatient service capacity or alternative to crisisservices Enhance communication among first responders and crisis serviceproviders Reduce the number of involuntary commitment (IVCs)From Wake County Behavioral Health Plan 2019-2020
Wake County Behavioral Health PlanObjectives 2019-2020 Set performance baselines and measure crisis system impact Quantify the need for additional psychiatric hospital beds and crisisassessment centers Pilot test program modeled after team in Austin Texas Expand funding for Partial Hospital Program designed to reduce LOS ininpatient setting Evaluate with Alliance opportunities for additional adult facility crisisbeds Work with Alliance to update CIT materials Review the impact on new crisis programsFrom Wake County Behavioral Health Plan 2019-2020
Crisis Services in Wake CountyProgressDorotheaDix stopsadmitting2010UNC begins tooperate WakeBrook;increases CAS to 8spaces20112012WakeBrookoperates CAS,FBC, Detox unitand 16 ionProgram2014UNC buildsadditional 12inpatient beds- new capacity28 beds;Increase CASto 12 spaces2015CASincreasedto 16spaces2016WakeBrookPrimarycare clinicexpandscapacityEMS createscoordinatedMobile Crisisteam to performcommunitybased assessment2017EmergencyDepartment& CrisisLeadershipbeginmeeting20182019Raleigh PoliceDepartmentcreatingACORN unit2020Monarch opensBehavioralHealth UrgentCare in WakeCounty2021Allianceopening ChildCrisis Service inconjunctionwith Kid’s Peace
Crisis Information - The Need WakeBrook (July 2019-June 2020) ER Behavioral Health Crisis Assessment Service (CAS) 6750 (563 ave per month)In Patient Unit (IPU) 691Addiction Detox Unit (ADU) 956Facility Based Crisis (FBC) 689Wake Med: average of 740 people per month with primary BH/SU issueRex: Psychiatry consults to ED 100 per month (underestimate as there aremany more people who present to the ED with no consultEMS (July 2019-June 2020) Total EMS calls--3605 680 linked to mobile crisisContinued with EMS--2925 550 alternative destination1636 ED739 no transport
EMS-Reason for ED Transport1%9%Center Capacity6%Medical ClearanceMedical Emergency17%Not Defined1%2%Patient Chose ED64%Psychiatric AcuityTier III Closing Time
Crisis Information - The Need Monarch Behavioral Health Urgent Care - For lower intensity urgent needs Raleigh Police Department calls Calls related to behavioral health CY2020 Total calls - 5521 Calls with suicidal ideation - 1153 Completed suicides - 27 Overdose calls - 995 Commitments with violent person - 269 Commitments with no mention of violence - 1283 IVC papers only - 1494
Crisis Information - The Need Impact of Enhanced/Integrated Primary Care Clinic Internal Data Improved quality of care After initial increase in ED visits (first year) there was a significantdecrease at year 2 Sheps Center Data (18 month study) Confirmed improved quality of care Decreased number of inpatient medical days When medical stay required shorter length of stay No increase in ED visits
Crisis System in a Medicaid ExpansionState-Tucson Arizona Tucson Arizona: Population 530,000; Pima County 1 millionCollaboration with centralized communication and time to implement fullcontinuum. Planning started in 2000 with implementation continuingCrisis Continuum:Crisis line Multiple Mobile Crisis team leading to 30 min response for calls from 1stresponders and 60 minutes for routine Crisis facility: Built 2011; The services 24/7 urgent care clinic23 hour observation unit—34 adult spaces and 10 youthSubacute inpatient unitRich staff of all disciplinesPost-Crisis Wraparound services 1st level of post crisis wraparound service house in crisis facility
SYSTEMvs. ServicesA crisis system is morethan a collection ofservices.Crisis services must allwork together as acoordinated system toachieve common goals.And be more than thesum of its parts.Slide from Margaret Balfour MDA crisis system needs a robust continuum ofservices to meet the needs of people in variousstages of crisis.23-hour StabilizationCrisis RespiteOutpatient ProviderFamily & Community SupportCrisis Telephone LineEARLYINTERVENTIONRESPONSEDept.WRAPCrisis PlanningHousing & EmploymentHealth CarePREVENTIONPOSTVENTIONMobile Crisis TeamCIT PartnershipEMS Partnership24/7 Crisis Walk-in ClinicHospital EmergencyIntegration/Re-integrationinto Treatment & SupportsPeer SupportNon-hospital detoxCare CoordinationTRANSITION SUPPORTSCritical Time Intervention, Peer Support & Peer Crisis NavigatorsAdapted from: Richard McKeon (Chief, Suicide Prevention Branch, SAMHSA). Supercharge Crisis Services, NationalCouncil for Behavioral Health Annual Conference, 2015.
Crisis Services Proposed Initiativesfor Discussion and PrioritizationEnsure a robust continuum of crisis servicesAExpand adult crisis assessment services capacity and add additional locations.BIncrease programs for youth in crisis.CExpand geriatric crisis assessment services.DPrepare for 988 suicide crisis line becoming operational in 2022.ECreate respite program (step-down) for individuals exiting healthcare facilities.FExpand mobile crisis service model in coordination with law enforcement and ensurecoordination between the various mobile crisis programs, EMS, LEO and direct callsto mobile crisisGIncrease size of psychiatric inpatient capacity.HDevelop a behavioral health emergency department.IExpand education to improve awareness of how to access crisis services.JProvide for initiation of medication assisted substance use disorder treatment inhospital emergency departments.KAdd telehealth as a means to access crisis services and WakeBrook CrisisAssessment Services.
WakeBrook operates CAS, FBC, Detox unit and 16 inpatient beds. UNC begins to operate WakeBrook; increases CAS to 8 spaces. UNC builds additional 12 inpatient beds - new capacity 28 beds; Increase CAS to 12 spaces. CAS increased to 16 spaces. WakeBrook Primary care clinic expands capacity.
