Apr, 30, 2021

American Rescue Plan Provides a New Opportunity for States to Invest in Equitable, Comprehensive and Integrated Crisis Services

Ashley Traube, Patricia Boozang, Jocelyn Guyer, Manatt Health 

Overview

The American Rescue Plan (ARP) Act enacted on March 11, 2021 establishes a state option to provide community mobile crisis intervention services for a five-year period beginning in April 2022. As an incentive to state adoption, the law provides for an 85 percent enhanced federal matching rate for qualifying services for the first three years of state coverage.[1] To further encourage states, ARP also includes $15 million in state planning grants to support their efforts to develop a state plan amendment or waiver request (e.g., Section 1115, 1915(b) or 1915(c)) to take up the option. The new mobile crisis provision arrives just as many states and localities are exploring strategies to address the worsening behavioral health—mental health and substance use disorder (SUD)–crisis (Box 1) – as well as preparing for implementation of 998, the new, national hotline for behavioral health crises. For states and localities reviewing their policing procedures, the new option also could be used to support state efforts to refine the role of law enforcement in responding to behavioral health crisis, offering more resources to the police on such calls or, in some instances, even entirely avoiding the need for law enforcement.

What Are Community Mobile Crisis Intervention Services?

Community mobile crisis intervention services are a critical part of states’ crisis and behavioral health systems of care. The Substance Abuse and Mental Health Services Administration (SAMHSA) National Guidelines for Behavioral Health Crisis Care, distill the elements of a crisis system into three core components with linkages to broader behavioral health continuums of care:

  1. Regional or statewide crisis call centers coordinating in real time;
  2. Centrally deployed, 24/7 mobile crisis; and
  3. 23-hour crisis receiving and stabilization facilities

Using this model, the regional or statewide crisis call center triages a call and dispatches a mobile crisis unit to respond to an individual in crisis. Mobile crisis teams – comprised of qualified professionals that are trained to de-escalate and treat individuals in crisis – work to assess and stabilize individuals experiencing behavioral health emergencies in the least restrictive setting and divert individuals with mental illness from jail and emergency departments to crisis receiving and stabilization facilities and other community based treatment.[2][3] Mobile crisis teams enable states and localities to begin to shift away from relying heavily on police, many of whom are insufficiently trained in behavioral health crisis, to other, trained first responders.[4]  Approximately 7-10 percent of police contacts involve individuals with mental illness which are very likely to result in arrest and incarceration, usually for minor offenses.[5] A primary police response to behavioral health crisis can criminalize and stigmatize mental illness and SUD, and make it more likely that the underlying mental illness or SUD remains untreated.

Why Are States Expanding Crisis Mobile Intervention Services?

Even prior to the enactment of ARP, a growing number of states and localities were reorienting their crisis response systems to include mobile crisis intervention teams and connect individuals in crisis to follow-up behavioral health treatment and recovery services.[6],[7] The mobile crisis state option is one critical tool available beginning in April 2022 to invest in comprehensive and integrated crisis infrastructure that will:

  • Stabilize individuals in crisis;
  • Connect them to follow up behavioral health services;
  • Reduce the stigma associated with behavioral health crisis; and
  • Lessen the reliance of communities on police as first responders.

Investing in a comprehensive crisis system that prioritizes behavioral health treatment can also help states and localities better support individuals residing in under-resourced communities who are less likely to be diagnosed with a behavioral health condition and connected to treatment.[8],[9] The option can also augment states’ efforts to ready their behavioral health crisis systems for the establishment of 988 as the national suicide prevention and mental health crisis hotline in July 2022.[10] Beginning in July 2022, states’ must have systems in place to route and address calls that come into 988.

What are Key State Questions on the New Option?

There are a number of key questions that states will need to consider as they begin to design or evolve their existing community mobile crisis services that align with the ARP Act provision.

What are Qualifying Community Mobile Crisis Intervention Services under ARP?

ARP defines “qualifying community mobile crisis intervention services” as services that are available continuously, and provided in a timely manner by a multi-disciplinary mobile crisis team that is:

  • Comprised of least one behavioral health professional who can conduct an assessment, as well as other professionals or paraprofessionals with appropriate expertise in behavioral or mental health crisis response, including nurses, social workers, peer support specialists and others;
  • Trained in trauma-informed care, de-escalation strategies and harm-reduction;
  • Provide screening and assessment, stabilization and de-escalation and coordination with health, social and other supports, as needed; and
  • Maintain relationships with relevant community partners, including a range of medical, behavioral and crisis providers.

What Are Some of the Promising Models for Crisis Mobile Intervention Services?

There are a number of different crisis response models operating across the country that are funded through a combination of Medicaid, state and other funding, and which leverage different professionals based on community need and workforce capacity. These are useful models for states to consider as they seek to develop community mobile crisis intervention services consistent with ARP service definitions.

  • Mobile Crisis Teams. A number of states—at least 13 as of September 2019–dispatch Medicaid-funded mobile crisis teams and least six other states and localities dispatch mobile crisis teams funded through non-Medicaid means.[11] Georgia’s Department of Behavioral Health and Developmental Disabilities provides mobile crisis services 24/7/365 on a statewide basis using a team of specially trained behavioral health professionals and para-professionals through its Georgia Crisis and Access Line. Mobile crisis teams respond within specified timeframes, depending on the urgency of the call, and provide on-site crisis management through assessment, de-escalation, consultation and referral with post-crisis follow-up to assure linkage with recommended services. [12]
  • Community Paramedicine. Community paramedicine programs expand the roles of paramedics and emergency medical technicians (EMTs) to provide preventive, primary care and population health services to support under-resourced communities. An emerging model of community paramedicine, mobile crisis management programs dispatch specialty trained paramedics and EMTs to respond to behavioral health crisis situations. North Carolina worked with its behavioral health managed care entities which manage publicly funded behavioral health services and select counties to pilot a community paramedicine mobile crisis management program. As part of the program, paramedics received advance mental health and substance use disorder training, and were dispatched to behavioral health crisis calls to provide triage, behavioral health crisis assessment, on-site intervention and referral to continuum of crisis intervention services and supports. Depending on the triage and assessment, community paramedics would treat and release or treat and transport to crisis receiving centers.[13]    
  • Co-responder Programs. Co-responder crisis intervention models pair law enforcement and behavioral health specialists to respond to individuals in behavioral health crises. Colorado’s Office of Behavioral Health operates co-responder programs throughout counties in the state using a combination of state and federal grant funds where a behavioral health specialist and police officer respond together at the scene. The co-responder teams provide on-scene crisis response, including crisis de-escalation, behavioral health screening and assessment, as well as call disposition planning. In addition, the teams also provide referrals and linkages to community-based services, outreach and linkage to families (as appropriate), peer support and care coordination.[14]

Which Populations Are Eligible to Receive Community Mobile Crisis Intervention Services?

States appear to have broad flexibility under ARP to tailor eligibility for community mobile crisis intervention services to any Medicaid eligible individual who is experiencing a mental health or substance use disorder crisis in a non-facility setting.

Most crisis services, including mobile crisis intervention services, are geared toward treating adults ages 18 to 65. This means that crisis supports are often lacking for special populations, including youth, older people, and individuals with co-occurring intellectual and developmental disabilities (I/DD) who experience behavioral health crises.

To address the growing behavioral health crisis needs of children and youth, states can consider designing youth specific models. For example, Massachusetts’ Behavioral Partnership provides child-centered and family driven mobile crisis intervention services for youth who are age 20 and younger through its Emergency Services Program provider. Mobile crisis intervention teams – comprised of master’s level clinicians with family and youth specific training and bachelor’s and paraprofessional staff – meet clients in home or school settings and work with youth and their families to de-escalate crisis events to avoid treatment in hospital settings and out-of-home-placements.[15]

Individuals with I/DD are more likely to be diagnosed with a mental disorder than other individuals, yet disability-specific crisis supports are often lacking for this population.[16] A number of states, including Tennessee, cover behavioral health crisis services for Medicaid beneficiaries with I/DD and co-occurring mental health disorders who are receiving long terms services and supports (LTSS) through Medicaid waivers. TennCare MCOs provide behavioral health crisis prevention, intervention and stabilization services for enrollees with I/DD receiving managed LTSS which include person-centered prevention and crisis prevention planning, training to caregivers, development of community linkages and cross-system supports and 24/7 crisis intervention and stabilization response.[17] In addition, states and communities may also incorporate I/DD trainings as part of their crisis trainings for first responders.[18]

Today, there are also significant barriers for accessing culturally competent mobile crisis intervention and other crisis services for Black, Latino and LGBTQ populations.[19] New ARP funding provides states the opportunity to design new or enhance existing community mobile crisis intervention services to be inclusive of the needs of these and other populations of focus. States can cultivate culturally competent mobile crisis intervention services by ensuring that crisis providers have an awareness of historical trauma faced by under-resourced communities, as well as mental health stigma which can act as a barrier to accessing behavioral health care for key populations of focus.[20]

How Can States Use the New ARP Option and Funding to Support a “Firehouse Model” for Crisis Services?

Currently, funding for state crisis systems is pieced together across a patchwork of funding sources and payers. Funding is also largely inadequate to sustain the crisis system using a “firehouse model” which refers to mobile crisis services providers who are “on-call” and able to be dispatched at all times to anyone in crisis regardless of insurance status – similar to other emergency services like fire departments. Medicaid can reimburse for crisis services delivered to Medicaid covered individuals only. Many private insurers may not cover crisis services. Taken together, these factors force states and localities to subsidize crisis services for insured and uninsured individuals using limited state and local funds which inhibit the access and availability of mobile crisis services across states and localities.

The state option for qualifying community mobile crisis intervention services represents a promising opportunity for states to better leverage federal funds to sustain their crisis systems and crisis providers. States that have expanded Medicaid will be able to claim 90 percent federal matching funds to support mobile crisis intervention services. For all other Medicaid enrollees, states will be able to claim 85 percent enhanced federal match on these services for the first three years of the option. States may consider developing or enhancing crisis provider reimbursement rates to reflect cost of making “on call” mobile crisis services available to Medicaid enrollees. As part of their mobile crisis design work, states may also consider extending emergency Medicaid coverage to individuals in acute behavioral health crises who are eligible for Medicaid but for their immigration status.[21]

By fully optimizing the new, enhanced federal funding for community mobile crisis intervention services, states may well be able to move their crisis systems closer to a firehouse model, and better target limited state funds to other aspects of the crisis system, such as readying the system for the transition to the 988 mental health crisis line. While the enhanced federal funding for community mobile crisis intervention services is temporary, states that have expanded Medicaid will be able to continue to draw down 90 percent federal match for services provided to the Medicaid expansion population.  

Conclusion

The ARP mobile crisis state option and enhanced FMAP provide a critical tool for states to invest in a more equitable, comprehensive and integrated crisis system that connects individuals in behavioral health crisis with specialized and appropriate behavioral health treatment. This option is just one piece of crisis planning that states and localities can undertake to fully transform their behavioral health crisis systems. The enhanced FMAP is temporary and only covers the Medicaid portion of the crisis system. This means that states must consider how to sustain investment in crisis services once the funding elapses and how to financially support a universal, payer blind system. This may include working with commercial payers, employers and other stakeholders to ensure adequate coverage and funding for crisis services beyond Medicaid. Additionally, significant community and stakeholder engagement and training will likely be required to design culturally responsive and equitable systems that individuals in behavioral health crises, their families, police, other first responders and behavioral health providers feel comfortable engaging. The ARP mobile crisis option and funding can jumpstart states’ efforts to reform their crisis systems.

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[1] Public Law No: 117-2. March 11, 2021. Available here.

[2] Scott, R. Evaluation of a Mobile Crisis Program: Effectiveness, Efficiency, and Consumer Satisfaction. Psychiatric Services. September 1, 2000. Available here

[3] Guo, S., Biegel, D., Johnsen, J., and Dyches, H. Assessing the Impact of Community-Based Mobile Crisis Services on Preventing Hospitalization. Psychiatric Services. February 2001. Available here

[4] Lowery, W, Kindy, K, Alexander, K, et al. Distraught People, Deadly Results. Washington Post. June 30, 2015. Available here

[5] Franz, S. and Borum, R.  Crisis Intervention Teams May Prevent Arrests of People with Mental Illnesses, Police Practice and Research. 2011. Available here.  

[6] New York City, Office of the Mayor. New York City Announces New Mental Health Teams to Respond to Mental Health Crises. November 10, 2020. Available here.

[7] City and County of San Francisco Office of the Mayor. San Francisco’s New Street Crisis Response Team Launches Today. November 30, 2020. Available here.

[8] NAMI, Black/African American, Available here.

[9] https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/

[10] Public Law No: 116-172. October 17, 2020. Available here.

[11] ASPR TRACIE. Technical Assistance Request. September 5, 2019. Available here

[12] Georgia Department of Behavioral Health & Developmental Disabilities. Guide: Using Mobile Crisis Services in Lieu of an Order to Apprehend. Available here

[13] North Carolina Department of Health and Human Services. Final Report on the Community Paramedic Mobile Crisis Management Pilot Program. November 1, 2016. Available here

[14] Colorado Office of Behavioral Health. Co-Responder Programs. Available here.

[15] Children’s Behavioral Health Initiative. Emergency Services Program: Mobile Crisis Intervention Practice Guidelines. Available here.

[16] Watson, A, Compton, M and Pope, L. Crisis Response Services for People with Mental Illnesses or Intellectual and Developmental Disabilities: A Review of the Literature on Police-based and Other First Response Models. Vera Institute. October 2019. Available here.

[17]Tennessee Division of Health Care Finance & Administration. Building “Systems of Support” for People with I/DD: Innovations in Behavioral Crisis Prevention, Intervention, and Stabilization. Available here.  

[18] See 14

[19] National Association of State Mental Health Program Directors, Assessment #8, Crisis Services: Addressing Unique Needs of Diverse Populations. August 2020. Available here

[20] Ibid

[21] Emergency Medicaid covers care and services delivered to an immigrant who is not lawfully admitted for permanent residence that are necessary to treat an emergency medical condition which could be expected to place the individual’s health in serious jeopardy; result in serious impairment to bodily function; or lead to serious dysfunction of any bodily organ or part. Source: 42 U.S.C. § 1396b(v)(3)(A)-(C).