Speakers: Mr Jamie Sellar and Emilie Awbery
Emilie Awbery: Hello everyone and welcome to today's webinar. Before we begin, I'd like to acknowledge the Traditional Owners of the land we're meeting on today here in Sydney, the Gadigal people of the Eora nation, and extend my respects to their Elders, past and present. I'd also like to acknowledge everyone joining us today who has a lived experience of suicide. Thank you all for being here. Before we get underway, I'll just, give you some brief background on our suicide prevention work here in New South Wales. Our work is guided by the strategic framework for suicide prevention in New South Wales, and we're working towards the Premier's priority to reduce the New South Wales suicide rate by 20% by 2023. The New South Wales government has invested more than 87 million in a new suite of initiatives known as the towards zero suicides initiatives. And one of these is the alternatives to emergency department presentations initiative where we will be establishing 20 new services throughout New South Wales to provide more suitable and immediate support for people experiencing suicidal ideation, than presenting to an emergency department. These services will link people with peer support and appropriate clinical care where needed, but also provide pathways into other services and supports to help address the causes of their distress. To help us think through about how we might develop these services, we're joined today by Jamie Sellar. Jamie is the chief strategy officer of RI international. He's here to talk to us about the Crisis Now model, which has been successfully delivered in Arizona, and a number of other States. And it's my pleasure to welcome Jamie today.
Jamie Sellar: Well, thank you Emily for that fine introduction. So as Emily mentioned, my name is Jamie Sellar. I'm the chief strategy officer with RI international. RI international is a large behavioural health agency non-profit headquartered in the United States. And really what we've been doing for the past 30 years is cutting edge work around psychiatric crisis services, generally going to be facility-based as well as outpatient programming. But RI began as and was a leader and a pioneer in the use of working with peer, certified peer support specialists in a role providing care for those that are currently in crisis. Our international is the second largest employer of certified peer support specialists in the US behind the division or department of veteran affairs, which is part of our federal government. In my role as chief strategy officer, I get the pleasure to consult both nationally and internationally around crisis system optimisation. And as a result, I could see the insides of an awful lot of facilities and mobile teams and call centres.
And what I'm going to do today is really talk a little bit about the Crisis Now model, which is a model that's been espoused by the national association of state mental health program directors, which in the US is the professional trade organisation for all of the behavioural health commissioners in all 50 States in the US territories as well. Now, Crisis Now is an easy read. It's about 60, 64 pages, not including the footnotes and references, bibliography types of pages. But I'm hoping that the discussion today leads into a brief overview of what the system looks like and can actually generate a better discussion during the question and answer period. Crisis Now came about through the work of the national action Alliance for suicide prevention came around in 2014,2015. And really, what it was, was a response to the surgeon general the US, a report on the national strategic plan for suicide prevention that really was highlighting the fact that in the US over the last 26 years, that suicide rates have been increasing. It's currently the 10th leading cause of death in the US. And while we're bending the curve backwards on the other nine leading causes of death in the US, unfortunately we have not been gaining ground. And in fact, more people are dying by suicide. Each and every year we anticipate about 47,000 people will die by suicide. In the sergeant General's national strategic plan, really the focus was on building resilience within families improving evidence-based practices. But there was a large portion of the talked about increasing access to care for those that were in a behavioural health crisis. As a result, the national action Alliance for suicide prevention did create the crisis services task force, which brought together 30 consensus national experts around the country on crisis. And this represented a large and diverse background. Folks that were direct care service providers, government agencies, funders and health plans, those that lived experience, peer run organisations, consultants policymakers, and with heavy input from first responders and medical leadership, who in the US are generally going to be the first line of defence for those that are in to behavioural health crisis. What they ended up doing initially was they started to take a look through the country to assume that some state was actually doing crisis work in a way that was going to be replicatable and sustainable.
And as they evaluated all 50 States in the crisis systems within them, what they realised that there was no state that was fully providing care in an, in an ease of access way in a sustainable model. But they saw some elements, particularly in two States, Arizona, which has incredible facility-based crisis services and incredible mobile crisis outreach teams and the state of Georgia, which has world-class mobile crisis outreach teams and a call centre that acts as an air traffic control hub. Now, there were other States that had components and opportunities to go ahead and look at, which included Colorado and New York. But really what the model was designed about was those three elements, call centres, mobile teams, and facility-based services. Now I want to go ahead and point to this particular slide because I think it's interesting. As we take a look at call centres particularly the Georgia crisis and access line, the Georgia crisis and access line, it takes the phone calls of crisis for the entire state of Georgia, over 10.6 million people. And over the last decade, they have been able to collect a massive amounts of data. So the task force was actually able to start to begin to look at the data in a way that I think was unparalleled anywhere else in the country and maybe anywhere else in the world. The level of care utilisation system is a patient placement tool that was created by the American association of community psychiatrists. And really what the goal is to look at people across six dimensions and come up with a score between one and six that would correspond to an appropriate level of care that would meet that person's needs.
This has been something that's been utilised in the state of Georgia for well over a decade, and that data has been collected for over that decade by the Georgia Crisis and Access line, one of the best call centres in the world. So, what we've got is 1.4 plus million datapoint scores on that locus. And what we tend to see is that people who are in crisis, their types of crises and the needs that they have do not always correspond with the types of services that they get. So, if you look at the screen, you can see that the numbers at the bottom for the locus range from one to six. One, two, and three are various degrees of outpatient services. They are basically outpatient services that are required. One is gonna be traditional outpatient. Three is going to be more of an intensive outpatient program. We can see at the far right that 14% corresponds to a level of six in the locus screening system corresponds to those folks that absolutely need inpatient support. Maybe even a little bit longer stay than a few days, maybe a five, six, seven or more day length of stay. What we do tend to see is that those folks that are in crisis really gonna fall more into the level four than the level five. At this point, I'm gonna talk about who gets the locus, who gets scored on the locus in Georgia. Usually, that's gonna be folks that are in crisis and need a high level of care. They either hit an emergency department, some form of crisis a psychiatric inpatient program or a mobile team. So, these are not everybody that feels they're in crisis. It's not gonna be given to folks that are able to resolve their own crisis through talking with clergy or friends or love ones to go ahead and get them through. But what we tend to see is that those folks that do require a higher level of care that the overwhelming majority are gonna be in the level four and five. And in the Crisis Now model, level four is gonna respond to the model crisis outreach teams and level five is gonna correspond to some form of facility-based service, short term in duration. And in the absence of these types of programs people tend to be moved up into the level six category requiring inpatient hospitalisation are moved down to a one, two or three level that may not suit their needs as well. So, as a result, when we see that the Crisis Now system is not in effect then we tend to overprescribe inpatient care cause it's not an appropriate level of care to begin with. What I'm gonna do now is go ahead and show a brief video that in about three minutes, it's gonna explain Crisis Now and then I'll do a deeper dive into the system itself.
(Video plays) Man: Drawn from current national best practices in crisis response, Crisis Now focuses on three components that help ensuring appropriate level of care to anyone in crisis. Component one, a crisis call centre staffed by specialists that coordinate all levels of crisis care. They evaluate the current crisis and can support and stabilise of the 90% of the cases they get. Those that need more get more. With these hubs dispatching appropriate resources and then supporting those resources and finding the best solutions. Component two, 24/7 mobile crisis teams that work in the street meeting people where they are and for the majority resolving their crisis right there. Despatched by the call centre hub, they lessen the burden on local police and reduce the stigma that some feel when a uniformed officer knocks on their door. Component three. Crisis stabilisation locations which constitutes the retreat model can offer short term care for people who need support and observation regardless of their level of crisis. These programs operate 24/7 and are the right door for everyone in a mental health crisis including those that may require involuntary treatment. These high-tech, high-touch facilities divert away from the emergency departments in jails while providing immediate specialised treatment. Police no longer need to decide between EDs or jail. The no wrong door approach reduces the time needed to handle these cases from hours to minutes and allows police to go back and supporting public safety, a role they're uniquely trained to do. Let's review the impact of the Crisis Now model in Maricopa County in Arizona, the fourth most popular county in the US. In 2017, Maricopa County police connected more than 23,000 people in a behavioural health crisis directly to crisis care. And those people were accepted 100% at the time. The Crisis Now initiative saves the time equivalent of 37 full-time officers reducing wait times in emergency departments for behavioural health patients by a total of 45 years. Saving local hospitals and emergency departments a total of 37 million in avoided cost and losses. Freeing them up to help the patients they're designed to treat while routing behavioural health patients to a course of care that's best suited to their needs. And reducing Maricopa County's overall healthcare costs by an estimated $260,000,000, more than twice that costs Crisis Now services. To learn more about how Crisis Now can make a difference in your community, go to crisisnow.com or download our white paper.
[music] [Video stops]
Jamie Sellar: So, these are the elements in the Crisis Now model. I'm gonna go ahead and start a little bit by talking about the fourth element that doesn't get enough prayers. But in the Crisis Now model, there is a commitment to essential principles and practices. These must include our recovery orientation, trauma-informed care, significant use of staff and really commitment to zero suicide in healthcare. The reality is that I'm going to a lot of facilities across the US and quite frankly frequently it looks like it could be a facility in the 70s, the 80s or the 90s. Crisis Now has a commitment to promoting evidence-based practice to ensure that the care that is provided to those who are most in need and most vulnerable is gonna be appropriate and help them through their crisis in a way that's gonna be helpful and beneficial for them. At the high tech crisis call centres in the Crisis Now model, and I'll go through a little bit more with you. I'm going to go ahead and be of an aircraft control variety which means that they're gonna have the high tech be able to follow somebody through the crisis centre from the time the initial call comes in until the time that person ends in a terminal which may be an outpatient program, which may be a mobile crisis outreach team. It may be any other number of services around there. In the best functioning system all crisis events have some connection to a crisis call centre. Even if it's just to create a record of service outcomes.
Think of this as a mental health specific zero, zero, zero. 24/7 that mobile crisis responds. These are gonna offer a level of care for those folks that are not able to be community stabilised within a high tech crisis call centre. Usually, it's about 10% all the time that somebody calls crisis call centre are gonna require a mobile outreach. These teams consist of two persons. One is gonna be a licenced professional counsellor, at least a licenced clinician, a couple, a pair of professionals. And their goal is to meet people where they live, work and play and to provide services in the community. Now the third level of care is for those folks that cannot be community stabilised by a 24/7 mobile crisis team, and that's gonna be crisis stabilisation programs. When operated correctly, these programs eliminate the need for emergency departments to receive primary mental health care patients and the Crisis Now model people are admitted directly into the crisis facility. And our years of service delivery, we see on average that only about 4% of the people seen actually require some form of medical clearance at an emergency department to begin with. So in the Crisis Now model really the model suggests operating as a no wrong door, accepting everybody and if somebody does need an emergency department visit after they've been seen at the facility, then work on a transfer to the emergency department with a transfer back when somebody is community stabilised. So I'm gonna talk a little bit now about crisis call centres. And this is gonna show the technology that's available today and really how a high speed crisis call centre is able to work. This is a model that's being utilised in the exemplar for Crisis Now for how a call centre should work which is the Georgia crisis and access line which is currently serving all 10.6 million people in the state of Georgia.
(Video plays)
Woman: By tracking all flights and giving each one the attention and support they need immediately when they need it. What if we could create a model for behavioural health crisis systems that could accomplish the same goals? What if we could use advanced technology to create a seamless network of support that engages a person in distress and doesn't lose connection until they are safely in the hands of the care they need? How might that change the experience for those in crisis? How might that improve our communities? Introducing Care Traffic Control, a cutting edge collection of software modules, each designed to improve a specific part of the care journey used individually for targeted improvement or altogether for an end to end solution, Care Traffic Control brings a new level of efficiency, transparency and value to your behavioural health system. The engage module is a comprehensive real time database that shows every intensive referral that is waiting for care, how long they've been waiting, and where they are waiting. Clicking on individual episode can drill down into important details like clinical triage and demographic information and cases can change colour based on wait time specials to provide an adequate status of a system throughput and ensure that no one slips through the cracks. The connect module provides 24/7 digital access to outpatient appointment slots and is designed to work in conjunction with call management software.
Users simply select whether a case has routine or urgent needs and the system will list providers and their next available day and time. The providers can even be listed in an order based on a customizable algorithm of your choosing that balances location distance from the individual demographics and appointment availability. The care traffic control bed track provides an up-to-date inventory of the status of every bed in your service area, including which beds are available, where they are, and what type individual can be placed in them. CARE2GO provides everything needed to dispatch, communicate with and track mobile crisis response teams. This GPS enabled system allows you to know where all of your teams are, what the closest teams are to the call and how long they been on their existing call. All information is sent via encrypted message and access through a secure site, so all clinical triage information is properly protected. Care Traffic Control metrics is a suite of customizable dashboards and reports that track all of your data in real time. This level of transparency allows you to practice valve management and allocate resources to maximise impact in the moment. And finally, our research and development team is creating a voice technology module that offers real time monitoring of the emotional distress of the caller so agents can understand if they're successfully engaging and calming the person in pain. These six care traffic control modules can be used individually altogether, or in any combination that best fits your system's needs. Your community ensures a vital safety net for fire and medical emergencies. It deserves the same for psychiatric crisis and Care Traffic Control delivers it in a manner that provides significant cost savings for your behavioural health care spent. (VIDEO STOPS)
Jamie Sellar: So in the Crisis Now model, you can see that these Air Traffic Control hubs utilise high technology to go ahead and ensure that people do not fall through the cracks. In the Crisis Now model really the recommendation is for large state-wide or at least large regional call centres to go ahead and ensure that people when they travel and migrate throughout their crisis, that there still as a central repository for their health information to go ahead and ensure that they're getting the best quality care that they can at the local level. I'm gonna talk a little bit now about crisis mobile outreach teams. So in the best systems, as I mentioned earlier, the crisis call centres should be able to stabilise 90% of the people that they get calls from and keep them within the community where they live, work and play. But we do know in sophisticated call centres that about 10% of the folks that they talk to are not gonna be able to be stabilised after an eight to 15 minute phone call. In those cases, the overwhelming majority or the overwhelming majority are going to have an appropriate response of having a mobile crisis outreach team come out into the community where people live, work and play to go ahead and provide support in that community. I really liked the way that they talk about a mobile crisis outreach teams in London. I was in the UK last year. We were talking about these services and they call them street triage. And really when I think of street triage, I understand that I'm meeting people at their place of work, I'm meeting them at their home, I'm meeting behind stores, I'm meeting them out in the street as opposed to what I see in frequently or I see frequently in US States where mobile team is basically one person who goes to a hospital emergency department to do a level of care assessment with somebody. And the Crisis Now model, by the time they hit the emergency department, the crisis system started to fall apart. The goal really is to have a two person team that's able to meet people where they are. In the crisis, now model these two person teams are kind of comprise of a professional and a paraprofessional.
The professional is going to be licenced or certified clinician, the table to do high quality risk assessment, treatment planning and all the things that you would need to ensure safety. The paraprofessional is gonna be a behavioural health technician or a certified peer support specialist is gonna help to provide another level of engagement for those that we serve. In crisis work, the number one factor is gonna be or the number one intervention is gonna be high engagement strategy. And what we have found is that when you have a two person team, you're increasing safety out on the street, which relieves the burden on law enforcement to come and be a second person to increase safety. But it's also increasing the opportunity for engagement. What we do know is that if you can engage a person and help them become an active participant in their own recovery, their outcomes are going to be much better, and you're going to decrease the need for higher levels of care. Now, unfortunately not everybody who gets a mobile crisis outreach team is going to be able to be stabilised and return back into their community. For those that can't be, the next level of care is going to be a crisis facility. These crisis facilities are going to operate under a no wrong door policy, which means that anybody that comes to the facility is going to go ahead and be accepted. And what I want to do is show you a brief video that talks about the evolution of the facility that RI international has created and run since 1996 in Maricopa County, Arizona, which is the fourth most populous county in the US we've learned a lot of lessons over the last 23 years. And I think that some of them may help to apply here in Australia as well.
[Video plays]Woman: ..hospital emergency department staff, then spend hours and hours in an ED or jail waiting to talk to a mental health professional, and days more before actually getting to a crisis service. This expensive, often inhumane approach, took some of the most vulnerable people on their worst days and put them in places that were never designed or equipped to help them. And sadly not much has changed in 30 years. This model is replicated thousands of times every day across the US. RI International realised that this broken system needed to change and created our first recovery response centre. The RRC offered an alternative to acute inpatient jail and emergency department - a place where a mental health crisis could be handled by professionals as immediately as possible. It was an improvement. However, it's still had some of the issues that plagued crisis care and ED'S, focusing too much on procedures and diagnoses and very little on engagement and collaboration. We realised that the hospital model was built to treat disease or injury. A new model would have to be developed to handle the unique needs of those in debilitating emotional pain. Thus, the evolution of the RRC began. We invented the living room model featuring a strong focus on good contact with the person in distress. There were new staff types as well. People with their own lived experience in mental health who are uniquely able to provide empathetic trauma informed care. The facility transformed from a colder, more sterile, traditional medical setting to have a warm, inviting feel. But there was still potential to make real community impact. Since most acute cases were being diverted to traditional crisis facilities. The next evolution would feature a no wrong door approach. Now all individuals in crisis are welcomed in and the fusion model was born. Combining the direct and safe access of a hospital ed with the recovery oriented approach of the living room. Since 2015, the Arizona RRC admitted 20,000 plus consecutive guests from the back of police cars. That's four fifths of all guests receive and has not refused a single person. Half of these guests are involuntary, but unlike entering a hospital or jail, these individuals are immediately welcomed by a peer staff who orients them to the care they will receive. There's active engagement and collaboration through out their stay. And they become active participants. Crisis becomes an event to be resolved and stabilised versus a diagnosis to be treated. And since law enforcement engages in zero wall time by bypassing the ER completely. And we're back on the street in less than five minutes, the burden on the police is ease. And the experience for the person in crisis is improved. Word of the success is spreading. The fusion model is now being implemented in facilities across the country often by funder requests. This evolution has been decades in the making, but communities just starting their journey don't need to evolve on their own. The crisis is now and the time is now. To learn more about the recovery response centre or how a true facility based crisis centre can support your community. Visit rainternational.com/fusion.
Jamie Sellar: So I'm going to talk a little bit more about what a true crisis facility needs to be. In order for a facility to work, it needs to work under a no wrong door approach. What a no wrong door approach means is that anybody that comes to the facility is accepted for treatment, triaged assessment. That nobody is turned away prior to coming into the facility. If people are turned away, the community tends to revert back to taking people to emergency departments in jails, bypassing the crisis centres altogether. Police and ambulance services won't risk being turned away. They will continue to utilise gels and ed's. Because ed's and gels currently do operate under a no wrong door approach. So what does it take to be able to provide that no wrong door philosophy and that approach? As you saw in the video since 2014, RI international has taken 20,000 folks out of the back of a police car and said yes 100% of the time. Now out of those folks, some are going to be voluntary, over half are going to be in voluntary. A lot of going to be intoxicated. If you are going to be sober, many are going to be aggressive as many as 3%, and many are going to be non-aggressive. So the reality is that in order to go ahead and provide a new no wrong door service, you have to be able to work with voluntary, intoxicated and aggressive people. Your program has to be set up to be able to do that. Because once again, if you don't, what you tend to see in the community is those that are going to be able to access, utilise your service police departments, ambulance services, outpatient clinicians referring. Are going to go to a door that they know is going to always be open. And that's going to generally be the jails and the emergency department systems. What makes this a little bit different than traditional inpatient programs is that in a crisis facility, the focus is on stabilising the presenting issue. The reason that somebody is in crisis in the beginning and really there's a focus on a fast throughput. So what is intriguing and interesting about these programs is going to be just how quickly people becoming can move through crisis. So if I take a look at crisis, a crisis event in itself is going to be a time or a time limited of them. Even without treatment. People in crisis are going to work through their crisis. You never see people that are in crisis for three, four, or five years. Generally you're going to work through it. The goal of a crisis facility is going to be to decrease the frequency, intensity and duration as quickly as possible with the goal of stabilising somebody and returning them back into the community. Where we feel they can get the most benefit from ongoing therapy and ongoing community stabilisation and supports through that. So it's going to be a little bit different than a traditional inpatient hospital. These programs certainly are going to be able to do everything that an inpatient facility can do. They can go ahead and do medication, 24 hour nursing staff, 24 hour psychiatric or psychiatric nurse practitioner coverage. But [inaudible] is going to have a focus on crisis stabilisation versus a focus on diagnosis and potentially treating that diagnosis. Now I want to talk a little bit more about some of the differences. So Steven Scott asked me a question last Friday at the conference. And it was a great question.
It was a question I've actually been waiting three years to hear. He was the first person to go ahead and ask and the question really kind of came back to is from a culture viewpoint, can current mental health wards that might have a high length of stay, start to adjust their culture, and I'm paraphrasing, but start to adjust their culture to get some of those shorter-term lengths of stay that we see in a crisis facility? So, if we take a look at a fully functioning, sophisticated crisis centre, the majority, over 50% of the folks that are seen are going to be stabilised and returned back into the community within the first 24 hours. What we're going to see is those folks, as many as 30%, that cannot be stabilised in the first 24 hours are going to then get transitioned into a short-term psychiatric bed with an average length of stay of about two and a half to three days. So, within that model, we're going to see that 90% of the folks that are coming into a crisis facility are really returned back into the community within the first four days. Now, this is in difference to what we see in most mental health programs across the country in the US, of average length of stay between seven and eight to as many as 11 or 12 days. Now, the reality is, is that making or working with an inpatient facility that has a culture of a longer-term length of stay should be working with the most acute folks in the community. They're going to have a tough time moving from an average length of stay of 10 days, for example, down to an average length of stay of five days, whereas, in a crisis facility that is focused on high cadence, fast recuperate, stabilisation is the goal, actually already begins with a culture that success is if we're able to return somebody into the community in the first 24 hours.
Success is if they do require a longer length of stay and we're able to return them into the community within four days and success is being able to identify those folks that are going to require a longer length of stay and get them into an appropriate course of treatment, predictably or presumably, a longer-term inpatient program so, there are some differences that a crisis centre has to operate differently than an inpatient program. I want to talk a little bit about some of the literature around some of these faster-paced programs. As you can see on the screen, this is published by SAMHSA, the Substance Abuse and Mental Health Authority for the Federal Government in the US. The current literature generally supports that crisis residential care is as effective as other longer psychiatric inpatient care at improving symptoms and functioning. It also demonstrates the satisfaction of these services is strong and that the overall cost for residential crisis services are less than traditional inpatient care. What we see in our programs is that the readmission rates for folks that are in our length of care for four days or less is going to be equivalent to the readmission rates for people who are in a longer-term inpatient program so, the reality is, extra days do not always make a difference as far as with the key performance indicators or the outcomes that you're looking for. We're definitely going to see higher patient satisfaction over lower lengths of stay so, once again, it comes back to a culture viewpoint. Are we looking to stabilise the crisis or are we looking to go ahead and resolve what the diagnosis is going to go ahead and be. In an apple for apple comparison, we're going to see that there's about the same outcomes that are going through. I want to show this just quickly and have a discussion about this. As we mentioned earlier, taking a look at the level of care utilisation system allows us to start doing some predictive modelling on what type of crisis a community will go ahead and have and then we can start to do some modelling around what kind of capacity does that system need to have in order to meet the needs of the community over the course of the year. This is a calculated projection that we did for the State of Indiana based on their 6.6 million population and we're able to kind of see that if they have an optimised system utilising the Crisis Now model, they can probably cut the number of inpatient beds that they have by about 75% by augmenting them with crisis beds, short-term in duration, and crisis stabilisation chairs which are these receiving facilities we've talked about, augmented with 49 mobile teams throughout their community. What we tend to see time after time when we look at the crisis system capacity and the calculator is that for every dollar you spend in a strong, coordinated crisis program or crisis system development, you tend to save two to two and a half dollars of unnecessary over-prescribed inpatient spend. I don't believe these numbers are going to perfectly match up with Australia. There are some significant differences in the amount of people that tend to come and see services within Australia and the types of care and systems that are already in place, police departments versus ambulance services that are doing the bulk of work out there in the community but, overall, I believe there is a way to go ahead and create algorithms that will be able to predict what your system, depending on the size, is going to need and how well you can start to align with crisis model principles so I appreciate the time today. I think we're going to turn it over for a few Q and A questions and answers and I look forward to a robust discussion, thank you.
Emilie Awbery: Thanks Jamie and thanks for sharing all that information with us and we do have an opportunity now for the viewers to submit questions. I just start by asking, I know you mentioned some of the results of the economic evaluation and the savings to the healthcare system, has there also been evaluation of the outcomes for the people seeking help?
Jamie Sellar: So, within the system in the US, it becomes a little bit more difficult to track somebody over the long term. We don't have a single-payer source so the folks that we see are going to actually be followed from the funding viewpoint by multiple people so, long-term follow up is difficult to do. What we can tend to see is going to be readmission rates, both three days, 30 days, even on rolling averages, and, what we tend to find is that readmission rates for folks coming back into a crisis level of care or needing inpatient hospitalisation is generally going to be under 15% so we're able to kind of see what the utilisation rates are starting to be but as far as being able to track somebody six months or a year out, we haven't been able to do that yet.
Emilie Awbery: And, you mentioned that I pioneered some of the work with peer workers in the model, could you talk a little bit more about the role of peer workers in the crisis stabilisation facilities?
Jamie Sellar: Absolutely, so once again, one of the differences that we tend to see between traditional mental health inpatient work and crisis work is that in crisis work, really what we're focused on is high engagement. People are going to have a baseline. The goal of crisis work is to help them return to what their baseline is going to go ahead and be with the understanding that once they return back in the community, that's where they should get their long-term supports, that's where their natural supports are going to be able to help them as well as their outpatient clinical teams to take them the rest of the way through there so, what we find is that some of the best people in the world to go ahead and engage people while they're in crisis are going to be people with lived experience that have maybe even gone through similar programs. So for RI international, what we tend to focus on is about 40%, 45% of the staff that we have working within our facilities are going to have lived experience and be certified peer support specialists. Now we do have in these programs, 24 hour nursing staff, 24 hour licenced clinicians, 24/7 psychiatric coverage. So all of the high tech that you would anticipate in order to ensure safety. But really it's a high engagement strategy that we employ a certified peer support specialist whose primary role is gonna be engagement specialist. Now RI fortunately is probably one of the largest trainers, if not the largest trainer, of peer support specialists in the world. So we frequently have the ability to hire some of the best and brightest peers in the country to go ahead and work into our particular program. But what we have found is through the use of folks who lived experience, we tend to get outcomes that we would not get if we ran just a straight professional or even, you know, even having a behavioural health techs that are bachelor's level you know, in psychology running on the floor. We tend to have lower seclusion restraint events, less hands on approaches. And I do think that it's instrumental in helping us to get those low average length of stay that we need. So RI international absolutely believes in peer work. We've been doing peer work really since the 90s and initially when there was no evidence based behind that we were doing the research to show that this is effective, it's safe and you're gonna get the outcomes that you're looking for.
Emilie Awbery: Just pick up on something that you mentioned there. We've had a question about the no wrong door approach and being able to accept people who might be displaying aggressive behaviours and what kind of strategies to use to ensure the safety of staff and other patients at the facilities?
Jamie Sellar: It's a great question, it's a complex question. I know that we've only got 23 more minutes. I could probably spend two or three hours with that, but I think first and foremost, it comes back to a lot of the little things that you tend to have. So what we tend to see in our programs is quite frankly, about 3% of the folks that we come in contact with to get admitted into the facility are gonna have some episode during their stay there predominantly in the first four hours. While they might still have some substances on board from the community. We get a lot of crystal methamphetamine in the states that people are using. I believe you might call it ice here in Australia as well as a high percentage of folks who are coming to our program on an involuntary status, which means someone else has made the decision that they need to be in our facility. They're not active participants in their own recovery at that program. So I think there's a lot of things that we tend to do to go ahead and support a decrease in the number of seclusion, restraint and number of violence that we have. First and foremost, I go back to our peer program. The first person that someone coming into the program is gonna meet is going to be a peer. They're gonna help normalise that process, they're gonna start the engagement process, they're gonna start to create the expectation of what someone can expect. So people are not in a position where they're wondering about what's coming next and allowing their agitation or anxiety to go ahead and increase. We create a physical plant that's gonna be soothing and calming. It's more of a living room feel. Now the reality is, isn't that living room feel, it's gonna feel much more comfortable for folks, but it's still gonna be absolutely say anti ligature, everything. The furniture we use is gonna be something that can't be weaponized. But what we're gonna see that's gonna be a little bit different than traditional inpatient programs. We're not gonna have plexiglass in our programs. What we have found is that the use of plexiglass creates an illusion of safety, but it actually decreased the safety because it removes patients from staff and engagement engagement's at number one priority. We're gonna have a staffing model that is consistent in the use of peers so that everyone has the attention that they deserve, so they're not sitting waiting for another intervention and then being left in another intervention coming through. We're really looking at helping getting people through the use of motivational interviewing to become an active participant in their recovery, to help them get through the process a little bit quicker. We're gonna be able to offer medication early and often, but once again, we're gonna have a staffing model that's built for those 3% that might need a little bit higher level of support. And we're gonna build our environment absolutely toward being safe, comfortable in working with that environment and it tends to work. Like I said, it's not perfect, but I'm very proud of the rates, low rates of seclusion and restraint that we have compared to inpatient hospitals that don't work with our particular model or even some of the other programs that are working in crisis found model but don't have the heavy focus on the recovery component that are I would have.
Emilie Awbery: I might just lay down from that by asking if you could describe a little bit more what the facilities are like. I think people might be interested to know what the setup is and especially for the shortest day guests come to the facilities.
Jamie Sellar: So overall what we're looking at is we're looking at two levels of care within one facility. The first is gonna be what we would call in crisis now at 23 hour observation unit. That's the true receiving facility. That's the one that's gonna be taking a hundred percent of the folks that are coming in. How we set that up from a physical viewpoint is we actually look at large open spaces. You know, the best programs that we can look at would be kind of a large box where there is a lot of room in the middle to go ahead and put recliners, couches, tables, chairs for people to go ahead and be able to kind of live for that first 23 hours around that big open area. January we're going to have rooms and those rooms could be kind of quiet rooms for folks that are maybe coming off crystal methamphetamine or needed nicer, quieter, darker place to maybe go ahead and rest a little bit, uh, during their initial stay as well as the, we can do family work, we can do individual work. We can ask some of those very complex and personal questions around suicide and do some of our intake and intervention work as well as meeting with the psychiatrist. So what we really are looking for are gonna be programs that for every 16 guests have about 7,500 square feet and really what our focus is gonna go ahead and be as big open floor plan so that all of the staff can see all of the patients, we're gonna call them guests and all of the staff can see each other as well. So it really does increase our safety, but it allows us to identify potential problems early. But we have seen the most difficulty with is programs that have hallways, blind alleys, blind corners. Now what's going to be a little bit different about the facility then at that point is we're going to have bright colours, we've got murals painted on the wall, we're going to have as much of a homelike field as possible. Like I said, a lack of plexiglass really with high engagement out there into the community. Bright lights, windows as much as humanly possible for natural lights to come in, which is a little bit different than traditional inpatient programs which are gonna try to have a nice clean sterile environment because it's easier for the facilities to stay clean. It's easier for housekeeping to go ahead and clean, it's easier if somebody punches a wall to go ahead and replaster it and paint it wide as opposed to repaint a mural that might be on that facility. But these are all the things that you need to do in order to get those low lengths of stay, without that, you're gonna see five, six, seven, eight, nine, ten day lengths of stay.
Emilie Awbery: And the facilities tend to be located in the community or close to the hospital centres.
Jamie Sellar: So, the programs in the US definitely are gonna be non-hospital based. They might be located close to a hospital, because once again, no matter what, you're still gonna get a large percentage of folks that are gonna be hitting an emergency department that need to be transferred over, and you wanna make sure that there's the lowest transportation cost as possible. But there definitely is a culture change between the traditional medical model and what crisis work is gonna go ahead and be. So, locating outside of an ER setting or a hospital, even if it's the parking lot, is gonna provide a lot of bang for the buck and benefit within those services.
Emilie Awbery: So, we saw in the presentation that there's these different elements of Crisis Now, including the facilities, and another one is the mobile teams. And one of the questions we've got here is about the qualifications or the skills of the people that staff the mobile teams.
Jamie Sellar: OK.
Emilie Awbery: If you could talk a little bit about how they work?
Jamie Sellar: So, once again, these mobile teams are gonna be working in communities. So, always gonna be a two-person team. And really, what we're gonna focus on is gonna be professional, licenced professional clinician. So, in the US, that might be a licenced professional counsellor, might be a licenced clinical social worker, might be a licenced marriage and family therapist. And really, with the focus that they have, is they have the ability to do the Columbia screeners and these other suicide risk assessments, to do a good psychosocial assessment, even the ability to go ahead and diagnose because that's gonna be important in certain components. And we have a lot of confidence in the recommendations that they have for continued care. Now, the second person we're gonna have in those teams are gonna be, generally, a paraprofessional. Sometimes, it's gonna be a licenced clinician as well if it just matches up that way, but it's gonna be probably more likely a paraprofessional. In the US, we have a behavioural health text status, which is, for someone who might have a Master's degree or 4-years experience working in the field, but are not in a position where they can be a licenced or independent clinician at that point. In the absence of that, what we really focus on would be a certified peer support specialist. So, the reality is, in the community, we like to have a clinician and a paraprofessional. And that paraprofessional is an engagement specialist. The clinician does the clinical work and we find that the best team possible. Now, when you do have those staff on a team, what you're able to do at that point is go into, for example, in Maricopa County, parts of South Phoenix that I wouldn't go by myself but if I've got a partner, I'm willing to go ahead and go. If I did have to go under those parts of South Phoenix by myself, I'd probably would have an over reliance on calling law enforcement requesting support while I go ahead and do my intervention. So, what we do tend to see is by having a two-person team, the professional can do the clinical, the paraprofessional can help support the engagement. You generally get the best outcomes.
Emilie Awbery: One of the viewers has asked about follow up after discharge from the stabilisation facility. So, who's involved in following people up?
Jamie Sellar: Another great question. So, part of the model that we're looking at - I'm gonna walk a long way down a short pier to come back to this answer - but if we talk about the cost-saving that this program has, in Maricopa County, we're anticipating that it saves about $260 million in unnecessary inpatient costs. The reality is Arizona, by utilising this model, has fewer psychiatric beds for 100,000 population than any other state in the country. And we don't have the same psychiatric boarding issues and we don't have the same amount of people going to jail as a result of a mental health issue and our law enforcement officers do have another option for them. So what we've been able to do is take some of that cost-savings and put it back into more preventative types of programs which means we have a lot of, what we call, assertive community teams that works with folks that maybe got a serious and persistent mental illness so we're gonna return folks back to that. In the absence of that, another program that we have created in Maricopa County is what we call peer navigators. And what peer navigators are gonna be certified peer support specialists. They're actually follow somebody post-discharge from the inpatient facility for two weeks until that person is engaged with an outpatient clinical team. And during that time, they're gonna drive that person to the first appointment if required. They're gonna help that person get their medication fill for the first time, navigate that system, as well as be there for support, just to kinda help somebody through those initial days coming out of the facility. Now that would not be possible if there wasn't cost-savings for this system as a whole to reinvest back into the system.
Emilie Awbery: Well, that actually leads into another question from a viewer here who's asked if you can talk about the ways that funding can be brought into the facility and into the different components of Crisis Now.
Jamie Sellar: So, I can talk about the US. I can certainly talk about the US. Currently, we're running 14 to 15 different inpatient programs throughout the US. And the reality is each one of them is funded differently. Some states want to go ahead and fund these as essential services. And what an essential service is it's fire and police. This is gonna be the service that you don't have to check an insurance card, you don't have to meet minimum qualifications. If there's a problem, somebody's gonna support you while you do that. Some states will pay for that. Some counties will go ahead and pay for that. In the absence of that, we do have insurance companies which are funders that should be required, or that are required to go ahead and pay for these services like they would an inpatient psychiatric hospitalisation or a medical component as well. So, in the US, there's a statement that if you've seen how one state does crisis, you've seen how one state does crisis. So, every state does it a little bit different. It becomes very creative in ways that you look for funding. What I believe the best system to be, generally is that crisis is seen as an essential service. It's paid for by the government for at least the first 24 hours which would cover the call centre, would cover all mobile teams, that's the first 24 hours. And would cover that first 23 hours in a facility base. That gives whatever facility enough time to go ahead and coordinate with other services to go ahead and ensure get the long-term help that they need. What that does is that means anybody in crisis has access to the appropriate care and never has to worry about the cost involved or if they're going to the right place or the wrong place. Under a no wrong door approach, you accept funding. It's nice to get funded for everybody.
Emilie Awbery: You've got kind of a big question here which is where do you start in trying to implement a comprehensive approach like this?
Jamie Sellar: That's another great question. So, there's couple of things. If I take a look at Crisis Now and we talk about some of the saving that we're gonna go ahead and see, the reality is the first system is a hole. You can start with pieces and plugging in things, but the reality is it's gonna work best when you start as a whole. If you can start as a whole with all three elements working in conjunction with good orientation, what I generally would start with is call centre. What call centres tend to do is they can say yes every single time somebody calls. What they also start to do is collect great data on what your system actually needs. So if in six months, you can make data-driven decisions about what the capacity of your locale may be as far as these other services. So, generally, if I'm gonna start it in a piecemeal fashion, I'd start with call centre because I love that data. I love that immediate response. Second, generally is gonna be the facility. I think the facility gets you a lot of bang for the buck and it really is diverting from emergency departments, jails, and law enforcement. And then third is gonna be the mobile teams. I've run mobile teams in Maricopa County. I think one of the few people that's actually worked in two of the, you know, four or five agencies that are seen as exemplars in Crisis Now. And the things is about mobile teams is they do have to have a (INAUDIBLE) for those 25 to 35% of the folks that they see. They have to have a place to take them other than the emergency departments. So, mobile teams do the best when they do have the facility as a back up and strong community resources is kind of a front door for them as well. So, if I was starting, I would start with the call centre, get all of that technology kind of put in place, start collecting your data, then make data-driven decisions about how we go from there.
Emilie Awbery: And there's a question actually about the call centres and what kind of stabilisation strategies are used by the call centre operators. And also whether they make referrals out to other services.
Jamie Sellar: So, I'm gonna go back to Georgia - Georgia Crisis JAMIE SELLAR: So, I'm gonna go back to Georgia - Georgia Crisis and Access Line which is really seen kind of an exemplar. I think it is the beacon that all call centres at some point should move to. So, what they have is, if you think about the calls that are coming in, it's truly mental health crisis line. It's not just a straight suicidal crisis line. So, the reality is, probably 70, 75% of the calls that are coming in are gonna be informational in nature. There's gonna be questions. There's gonna be concerns. I wouldn't consider that a hot, hot call.
Speakerdash1: that there is an immediate danger. Out of the additional calls, what you gonna find is a lot of those coming in hot, after 12 or 15 minute conversations, are gonna be stabilised to the point that they can be reintegrated back to the community. And about 10 to 15% of the time is gonna require some mobile outreach, you know, in-home type of care. Now, for Georgia, and what I really like about that and I've worked call centres as well, is that if it's 2am and I'm working with somebody and I feel if I could get them seen in the morning by a behavioural health professional, I could probably keep them out of a emergency department. I might not need to send a mobile team, I could probably keep them out of an inpatient psychiatrist, but my only option is to give them a phone number and tell them, "This place opens at 9am. Why don't you give them a call and see if you can get in today?" That's not really a good option. I'm probably gonna escalate it up the line. But, if I've got the technology that allows me to see open slots with my community partners and get them scheduled and say, "You're going at 10am to this particular place and meeting with this person. It's already been pre-arranged." I have a high rate of people going, a low rate of no shows, and I can start keeping people out of higher levels of care. So, the reality is, is that for a call centre work, it has to know where all the open beds are, all of the open outpatient slots. You're gonna go ahead and be - and it has to be the one dispatching and working with mobile teams for those times that it requires immediate response.
Emilie Awbery: And what are the qualifications of the call centre staff?
Jamie Sellar: So, in the United States once again, if you've seen one state, you've seen all states. Quite frankly, I do know some call centres that only employ licenced clinicians. My personal opinion and I guess I'm going on the record with that is I don't that's a level of care that's... I don't think the level of staffing that's absolutely necessary. From a sustainability view point, it's very expensive. For workforce development perspective, it's difficult to go ahead and get that many licenced clinicians at any one place at one time. What I do believe is a good model to have, is generally having folks that answering the phones that might be Bachelor's level or even below, with a very strong training component, as long as there is somebody of a higher level, maybe an independent licence that can take over at least support on calls that do have that higher intensity. So, the reality is, the majority of calls is not gonna require a licenced clinician. So, if I've got licenced clinicians taking calls that don't require their particular services, on some level, I'm wasting resources. But I want to make sure that everybody gets exactly what they need and if they can't get what they need with a Bachelor's level person on the phone, or maybe a volunteer with some specialised training, that they have the ability to go ahead and move that up that, move it up a rung on the ladder.
Emilie Awbery: The question next is about how the Crisis Now system evolved and came together and who were the sort of stakeholders that were first involved in getting the system going?
Jamie Sellar: So, in Arizona, many talk about Arizona, which I do think probably has one of the more advanced crisis, not just because I work in Arizona, but one of the more advanced crisis systems. The reality is, in the mid-80s, the State of Arizona was under a lawsuit. Basically, what we were doing is we were keeping people in our state hospital for an extended period of time, not because they require that level of care, but because we didn't have the community resources to go ahead and discharge them from the inpatient program. So, in the US, when you keep somebody against their will, you're violating their constitutional right to freedom. The Department of Justice and basically the state got sued and rightfully so as a civil rights case. If you're keeping people, not because it's good for them, not because they're a danger to themselves, because you have not put in place the appropriate resources, something's gotta change. As a result of that, they dramatically cut our inpatient amount of civil commitment beds to a ridiculous number
Speakerdash1: the lowest in the country. And as a result of that, we had to start scrambling. If the state hospitals were no longer an option for our most acute folks, we have to ensure that they don't get to an acute level that'd require that. Now, beneficially, at that time, the state realised under court order, that they needed to fund alternate levels of care other than the state hospital. And over the last 30 years, there have been a lot of pilot programs designed to keep people out of inpatient facilities. Now, the reality is a vast majority of the failed. But the ones that survived
Speakerdash1: good mobile teams, good call centre, good facility-based crisis systems - the ones that tend to evolve were the ones that have shown the ability to meet what the community needs are. So, the reality is, it started as a necessity and had a 30-year evolution. So, when the Crisis Now model was written, it came out in 2015. It had taken a look at what had taken really 30 years of evolution in Arizona to kind of accomplish. Now, I don't anticipate that any new program or new state would be able to go ahead and start immediately without 30 years, but I don't think it's gonna take 30 years for a program, for the crisis network to get where it needs to get to. You can learn from the lessons from Arizona and Georgia and some of the other states and move towards it much, much quicker.
Emilie Awbery: We've pretty much come to the end of the questions there. And unless there's any more questions from the viewers, we might leave it there, and thank Jamie for joining us.
Jamie Sellar: Oh, pleasure.
Emilie Awbery: It's been really interesting. Thank you, Jamie.
Jamie Sellar: Thank you.
