TO: Mayor and City Council
THROUGH:
FROM: Kristin Retherford, Acting City Manager
SUBJECT:
title
Exploring a civilian-led mobile crisis unit pilot project to respond to calls for service involving persons experiencing homelessness or behavioral health crisis, within the context of the existing services available in Salem.
Ward(s): All Wards
Councilor(s): All Councilors
Neighborhood(s): All Neighborhoods
Result Area(s): Good Governance; Safe Community; Welcoming and Livable Community.
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SUMMARY:
summary
In response to a January 10, 2022 City Council request for information, the purpose of this report is to define what mobile crisis response is and how it works in most communities, summarize available resources here in Salem, identify gaps in the system and impacts of cost to cure those gaps.
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ISSUE:
Information only.
RECOMMENDATION:
recommendation
Information only.
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FACTS AND FINDINGS:
Scope of Research. On January 10, 2022, Salem City Council requested a report regarding a civilian-led mobile crisis unit pilot project to respond to calls for service involving persons experiencing homelessness or behavioral health crisis, within the context of the existing services available in Salem.
Staff were tasked with identifying potential community partners (such as local non-profits, medical service providers, behavior health providers, local governmental entities), staffing, funding sources, cost of pilot project, potential service providers, hiring and training resources for unit personnel, outline of the continuum of related services currently provided, what it would take to expand existing law enforcement and qualified mental health professional Mobile Crisis Response Teams (MCRT) to 24 hours a day seven days a week, how a civilian-led mobile crisis unit would fit alongside existing public safety programs, and how this service may impact dispatch and any associated staffing, technology and protocol issues.
To accomplish this project, staff conducted research and consulted with CAHOOTS (Eugene), Portland Street Response, Olympia Mobile Crisis Response, Northwest Human Services (Health Outreach), Marion County (Health and Human Service, Acute/Forensic Behavioral Health), non-profit community partners, Fire/EMS, 9-1-1 Dispatch, and Police Department staff.
The purpose of this report is to define what mobile crisis response is and how it works in most communities, summarize available resources here in Salem, identify gaps in the system, and impacts of cost to cure those gaps.
SUMMARY
What is mobile crisis response?
In most communities, a mobile crisis response is typically a triage response to an incident or a person exhibiting signs of physical, mental or emotional distress out of doors. The goal is to safely respond to a person in need in outdoor environments like a sidewalk, camp, or other public space. This could include situations like an intoxicated person in a public location, a person experiencing psychosis, an individual disrupting the peace or exhibiting signs of visible distress.
A team of at least two staff respond to calls for help. Teams are comprised of a mental health professional (qualified mental health professional or a social worker) paired with a basic medical professional (emergency medical technician (EMT), community medic, or a registered nurse) who respond to someone experiencing a low acuity behavioral health crisis. These teams treat the immediate crisis and pass on resources or referrals in certain situations and locations. Most programs will not enter a private residence, nor respond to incidents involving weapons or threats of violence
How does it work?
An individual may call for help when encountering or witnessing a person in distress or exhibiting erratic or unexpected behavior. Calls may be received from 9-1-1, a non-emergency law enforcement line, street outreach workers, or community-based organizations in the field. Support may be requested by street outreach teams or law enforcement in the field. Sometimes, law enforcement, an ambulance unit, or a mobile crisis team may self-dispatch to a situation.
If the request for help is to 9-1-1, the caller is asked a series of questions to help the dispatcher determine the best resource to deploy. If determined to be appropriate by dispatch, a team comprised of a medical service professional and mental health professional will respond. For calls in which the safety of the person or of others is of concern, law enforcement will be the first responder. For higher acuity medical calls, an ambulance or firefighter/EMT will be dispatched by 9-1-1. Most higher acuity health calls end with transport to the hospital emergency room.
Most communities with such programs report fewer calls for mobile crisis response services into the afternoon and evening, as fewer erratic or concerning behaviors are observed and reported.
Who provides the service?
In most areas, mobile crisis response teams are provided directly by the local municipal government - either as a part of the police department or the fire department. One program, offered through a contractor in its pilot phase, was absorbed due to pay equity and labor concerns. When it was brought in-house, costs increased.
What are the desired outcomes of the programs?
The goals of the programs studied differ and may be diversion from jail or the local hospital’s emergency department. In some areas, the mobile crisis response takes care of immediate basic needs by providing water, snacks, clothing, and basic first aid. Transport, if requested, may be offered to other, public spaces, day centers, or low barrier shelters. In other communities, the mobile crisis response may be a point of entry to other available services such as a health clinic, psychiatric crisis care, detoxification, or addiction recovery programs.
All cite some common shared challenges. One is the critical need for stabilization resources such as housing to continue treatment for the underlying issue that led to crisis. Most existing programs are also experiencing staffing challenges particularly in hiring behavioral health staff and case managers. Despite recent emphasis on employing peer support in service delivery, some programs are encountering safety issues with sending peer support into situations which may be triggering for the peer.
WHAT HAPPENS IN SALEM
For a graphic depiction of the workflow, refer to Attachment 1. Based on available information, 9-1-1 dispatchers may elect to send medical response, law enforcement with behavioral health emphasis, or law enforcement. This decision is based on the questions asked, the information provided, the perceived risk to individual(s) in the incident report, or responders to the incident. Law enforcement officers, fire fighters/EMTs, and street outreach workers in the field may self-initiate a call.
When arriving on scene, first responders will screen and assess, triaging immediate security threat, behavioral health, or medical need and offer referrals to other services. Referral, depending on acuity of crisis and resource called for support, may function as follows:
• If law enforcement is sent, the officer will determine if Peace Officer Custody is required (if the person is a danger to themselves or others) or if a crime has been committed.
• Transport to emergency room. Firefighter/EMTs will transport to emergency room, unless service is refused. Police officers can place a hold for further evaluation.
• Transport to Psychiatric Crisis Center (if individual is willing)
• De-escalate and disengage. Officers have no mechanism to make the person behave or go somewhere when they do not want to go, and do not transport someone who is on the verge of crisis to a community partner that is not equipped to deal with them as that could create more issues for the person or partner agency.
• Law enforcement may transport to temporary or emergency shelter, if the person is willing and space is available. When the Navigation Center is open, this low or no-barrier shelter will offer another option for some immediate sheltering.
What resources may be called to help? A new, civilian-led mobile crisis unit would not replace existing public safety programs - such as Salem Police collaboration with Marion and Polk County in Mobile Crisis Response Teams or (MCRT) or Marion County Law Enforcement Assisted Diversion (LEAD).
• Mobile Crisis Response Team (MCRT). Salem’s grant-funded behavioral health unit is the result of a partnership between Marion and Polk County Health and Human Services and Salem Police Department. MCRT consists of an officer paired with a qualified mental health professional (QMHP). This service is provided from 8 am to 12 am, seven days a week. Dispatch triages requests for emergency medical service or Mobile Crisis Response Team (MCRT). The teams are dispatched to respond directly to active mental health crisis calls. The specially trained officer works in conjunction with the mental health professional to provide clients with the services they need to prevent incidents from escalating.
Currently, the MRCT program operates in conjunction with both Marion and Polk counties through intergovernmental agreements and grants. Outreach partners are regularly contacted for assistance and referral. Funds are currently provided from Marion County, who applies for a grant from Oregon Health Authority. If this unit is out on another call or not available because no team is scheduled when a call comes in, Dispatch sends the next best available resource. In Polk County, this service will be offered through Polk County Sheriff’s Office beginning in April 2022.
• Psychiatric Crisis Center (PCC) is located on the hospital campus for 24/7 in-patient care. It requires voluntary participation. This service is a Community Mental Health Program (CMHP) operated by Marion County Behavioral health and receives funds from Oregon Health Authority for behavioral health crisis care and mobile crisis funding. It operates 24/7 to provide 23-hour respite care:
o Referrals from law enforcement, self-referral, Dispatch (may send call to PCC, depending on the acuity of the caller’s need, for immediate phone consultation)
o Serves about 5,000 per year (not unique visits; could count one person’s multiple visits)
o May call 9-1-1 once or twice a quarter for help with detox
o If an individual has Oregon Health Plan or a primary care provider, they can move from case management into the health system (takes two to three days for crisis subscriber)
• Law Enforcement Assisted Diversion (LEAD). The goal with LEAD is to deflect low-level offenders from the criminal justice system, thereby reducing the harm a person with frequent offenses causes him or herself, as well as the harm the individual may be causing the surrounding community. Those referred to the program must meet criteria set by the Marion County District Attorney’s Office based on past criminal history and type of crime being diverted. Enrollment is voluntary.
• Street Outreach. These teams meet people where they are experiencing crisis and offer support and referrals to individuals exhibiting disruptive, but non-criminal behaviors. Participation is voluntary. Current outreach services are provided by an array of individual volunteers and organizations. Within our community, street outreach is provided by Union Gospel Mission (UGM), ARCHES, Salem Housing Authority, Church of the Park and Be Bold Ministries. UGM and ARCHES have access to a vehicle for transport.
o Northwest Human Services Health Outreach (NWHS) offers street outreach to connect willing persons to other medical services at their Clinic. NWHS is a federally qualified health center (FQHC) like Whitebird in Eugene and works collaboratively with law enforcement on individual cases with a focus on care for individuals who are experiencing homelessness. Services are often offered on a scheduled basis and may provide resources or referrals and assistance with problem-solving, conflict resolution, and relationship building. The goal is to build trusting relationships with - and determining the need of - people living on the streets to help people who are homeless move from the streets into a permanent home.
The NWHS crew primarily focuses on chronically homeless individuals in the downtown area. Staff have crisis intervention and mental health training in de-escalation techniques (QMHA level, under QMHP supervision) and partner with a registered nurse to triage in the field and transport if necessary. The purpose is to connect, provide quick medical care, and stabilize the crisis. The crew is dispatched from NWHS’ Mid-Valley Resource website’s outreach request form, other community providers/street outreach, and monthly coordination with Salem Police. The service runs three times each week during daylight hours for safety, connects individuals to services, and picks them up from service providers or parks for transport to medical providers. HOAP (Homeless Outreach and Advocacy Project), another NWHS program, offers medical team services with psychiatric care for adults facing homelessness. The service is not an immediate response, nor available 24/7. Medical or mental health emergencies are referred to 9-1-1. As a FQHC, NWHS works with area partners and connects individuals to medical services.
o Be Bold Ministries offers 24/7 immediate response to those experiencing homelessness and provides access to a range of services, including medical services (NWHS), behavioral health care (PCC), supplies, temporary emergency shelter, etc.
o ARCHES Project provides some scheduled outreach. ARCHES operates a drop-in day center at their primary location and provides supportive services and access to basic necessities at this location. Housing referrals and navigation-centered case management are available to all clients.
o Church at the Park offers case management and scheduled outreach to encampments, in addition to management and security at Safe Park and micro-shelter community village sites.
o UGM Search and Rescue offers aid and support to men, women, and children residing in homeless camps throughout Marion and Polk Counites. The Team operates out of a mobile van. Essential items, a loving ear, and invitations back to the Mission for meals, shelter, and services are extended. Other UGM services include location-based meals, shelter, and recovery program.
o Salem Housing Authority (SHA) housing navigators and street outreach connect people to resources and operate the City’s housing rental assistance program (HRAP).
o Recovery Outreach Community Center is location-based and offers support services at community center, over the phone, and by Zoom.
What are the gaps in Salem?
Staff who visit people in distress, in Salem and in other communities, often report a temporary de-escalation of the situation. While temporarily able to help the person, once the team leaves the site or the triage support ends, providers often note that issues re-escalate. Stabilization of a person’s needs generally requires more than basic health services. It often requires additional support, such as a safe shelter bed, a safe place to sober, or a community-based mental health service provider. The community needs additional locations (temporary or emergency housing, with wraparound services) to help people stabilize and connect to more services and permanent housing. Specifically, gaps include:
• Immediate access to stable housing. The community needs more shelter vacancies and variety of shelter types (outdoor managed camping, safe vehicle parking program vacancies, low barrier shelters). The primary gap for stabilizing those in crisis is accessing housing. This is also a concern in our Homeless Rental Assistance Program in which the case managers, even with wrap around services, are no longer able to place program participants in privately-owned market rate housing. The behavioral health issues among the population are too significant for many individuals to make the transition to this type of scattered site housing environment. While the Navigation Center, when open, will help as an interim step in the transition to permanent housing, the community needs additional housing with a mental health focus and on-site mental health services.
• Prioritized response to calls. Salem Police continue to respond to emergency requests for assistance. Given current staffing levels, there are some calls that Salem Police may not be responding to, such as disruptive but not criminal behavior, or smaller scale vehicular accidents. If there is an acute medical crisis occurring, Salem Fire/EMS is dispatched. Emergency services may not be dispatched or responding to lower level medical or basic health requests for assistance.
• Basic health response. The current response is provided by our street-outreach partners: Union Gospel Mission, ARCHES, Salem Housing Authority, Church of the Park and Be Bold Ministries. UGM and ARCHES have access to a vehicle for transport. Coordinating a basic health, lower acuity response from 9-1-1 Dispatch would provide for a timely response to individual needs.
• Other service system supports. Other gaps in the system include a place for individuals to become sober and potentially connect to other treatment options, and more places for individuals to safely experience psychosis or other behavioral health crises.
Filling the Gaps
Adding three elements to our existing service system would improve conditions, help meet community needs, and mitigate immediate crises. The cost of adding these services is approximately $5.3 million:
1. Expand MCRT to 24 hours. This would require three additional officers and three qualified mental health professionals, working under the direction of an existing supervisor. To staff MRCT 24 hours a day would cost an additional $567,000. This assumes a Salem-based MRCT service, in addition to the existing partnership with Marion County. If the goal is to create a 24-hour MRCT within Salem Police, including hiring QMHPs, six additional officers and six qualified mental health professionals will be needed. This would be at an additional cost $2.4 million. Two additional vehicles would need to be purchased in the first year.
2. Offer in-field paramedicine. This is modeled after Portland Street Response and involves sending medical and mental health care teams to provide basic health care and transport when the situation does not require urgent medical response via ambulance. A new street response team could help mitigate immediate crises. To staff a new van service for 24/7 coverage would cost $2.3 million. Staffing for each of six shifts would consist of a basic EMT, a mental health crisis responder, a peer support specialist, and a community health worker. A one-time vehicle cost is expected to be approximately $145,000 for two vans. EMTs operate under a medical director with a clear set of protocols.
3. Add Capacity to 9-1-1 Dispatch. Calls are already being received for these types of services at Willamette Valley Communications Center (WVCC). We expect call volume will increase as the new service is added and community awareness of the new service grows. We expect, based on the experience of other communities, that adding this additional step to triage calls will extend call times. To mitigate this effect, staff are recommending adding capacity to WVCC by hiring additional call takers. This will cost an additional $2.4 million for two new dispatch stations staffed with 14 additional FTE to achieve 24/7 coverage of the two new workstations. In addition to mobile crisis response, a pilot implementation of 9-8-8, which will replace local crisis/suicide prevention line, is planned for the next couple of months. Call volume within WVCC is expected to increase when 9-8-8 is rolled out. It remains unclear at this time how triage for this service is coordinated between 9-8-8 and 9-1-1 for the best response to person experiencing crisis.
On a limited duration, initial pilot basis, it may be possible to consider a low acuity health/behavioral health team response for 12-hours (not 24 hours) and expansion of WVCC capacity for that 12-hour shift for approximately $3.5 million.
Key Findings: Other Communities
• Potential partners. Collaboration in this field is critical. Salem is already collaborating with many community partners (local non-profits, medical service providers, behavior health providers, and other local governmental entities) in the current system. Staff are also in conversation regularly with our area counties, Northwest Human Services (our area FQHC), and Pacific Source, Kaiser Permanente, and Salem Health.
• Potential funding sources and service providers. When provided by FQHC, some of the services may be eligible for Medicaid, Oregon Health Plan reimbursement. If this service - a behavioral health/basic medical response team - is sought from a contractor, a full business case analysis should be requested from the provider in the RFP. Any potential service provider would need to hire multiple new staff and acquire new vehicles to provide this service 24/7 in our community. Hiring and training of unit personnel would be dependent on the provider. Training is available in crisis calls from DPSST. CAHOOTS is building a planning workshop. There is a national network of organizations providing these services.
• Cost estimate to stand up service. With CAHOOTS as the exception, these services tend to fold into direct city service provision due to pay equity and/or labor agreements, complexity of sharing dispatch systems. With a focus on behaviors of concern, not housing status of individual, the response would be available to all experiencing low acuity health or behavioral health crisis.
• Staffing. On the behavioral health side of the team, staffing has included QMHP, social workers with experience and skill in trauma-informed care. On the basic health side of the team, staffing has included EMT, community health EMT, and registered nurses. All teams build in supervision for both sides of the team. Some teams have added a peer support role as an additional team member - not at the exclusion of the behavioral health or health care designate.
Models in Other Communities
CAHOOTS. CAHOOTS <https://whitebirdclinic.org/cahoots/>, Crisis Assistance Helping Out On the Streets in Eugene, is a mobile response pairing together a crisis intervention worker and an emergency medical technician, staffed by White Bird Clinic personnel using City of Eugene vehicles. This relationship has been in place for nearly 30 years and is well embedded in the community and is viewed as part of Eugene and Springfield’s emergency response system. Provides non-emergency medical care, first aid, transportation (but not to private residences). Focus is on crisis counseling, suicide prevention, conflict resolution, welfare checks, grief counseling, medical care, resource connection, transportation services, substance abuse counseling, and first aid. “Any person who reports a crime in progress, violence, or a life-threatening emergency may receive a response from the police or emergency medical services instead of or in addition to CAHOOTS.” CAHOOTS is attached to Eugene Police Department and Springfield Police Department.
• Staffing: Staffed and managed by White Bird Clinic; Medic (nurse or EMT) and crisis worker (experience in mental health field).
• Calls for service: Calls that may be considered non-emergency in nature, not requiring Police or Fire/Emergency medical attention, are dispatched to the mobile response team. Dispatched through Central Lane Communication Center (Eugene police-fire-ambulance communications center), Eugene Police non-emergency number and Springfield Police Department’s non-emergency call takers.
• Cost: City of Eugene (Police Department) per IGA, July 1, 2022 through June 30, 2023: not to exceed $835,656; City of Springfield, Lane County, and donations.
Other resources and information:
• Free response is available for a broad range of non-criminal crises, including homelessness, intoxication, disorientation, substance abuse and mental illness problems, and dispute resolution. White Bird Clinic, a federally qualified health center (FQHC), offers services, including: Crisis Service Center, counseling, Chrysalis Behavioral Health outpatient service, dental clinic, medical clinic, day center with clothes and restrooms, a teen-centered program in high schools, and case management.
• Central Lane 9-1-1 Dispatch Workflow <https://www.eugene-or.gov/DocumentCenter/View/56581/911-Process-Infographic>
• Eugene Police Department assessment of CAHOOTS call diversion <https://www.eugene-or.gov/DocumentCenter/View/56717/CAHOOTS-Program-Analysis> (August 21, 2020)
• The City of Eugene funds CAHOOTS through the Eugene Police Department. In Fiscal Year 2018 (July 2017 to June 2018) the contract budget for the CAHOOTS program funded 31 hours of service per day (this includes overlapping coverage), seven days a week. One van was on duty 24 hours a day and another provided overlap coverage 7 hours per day.
• Over the last several years, the City of Eugene has increased funding to add more hours of service. The Fiscal Year 2020 (July 2019 to June 2020) budget included an additional $281,000 on a one-time basis to add 11 additional hours of coverage to the existing CAHOOTS contract. CAHOOTS was able to add 5 of the 11 hours of service to bridge an afternoon gap to maintain two-van coverage. The city carried over the funding for the 5-hour expansion through Fiscal Year 2021 (July 2020 to June 2021).
Portland Street Response. <https://www.portland.gov/streetresponse/psr-faq>. The goal of Portland Street Response (PSR) is to update the first responder system by providing an additional compassionate first response option when 911 is called on someone experiencing homelessness or a low-acuity behavioral health issues, not to solve homelessness. Portland Street Response is coordinated by Portland Fire & Rescue for several reasons: 1) the program needs infrastructure that is connected to the current 911 system; 2) Portland Fire & Rescue’s Community Healthcare Assessment Team has already built the foundation for Portland Street Response; and 3) it follows the directive to keep this program separate from police.
Staffing: Portland Street Response Staffing (aimed at crisis engagement, working with chronically homeless) includes:
o Health worker: Community health EMT (not firefighter/paramedic)
o Mental health worker: Social worker with conflict resolution (doesn’t need to be qualified mental health professional (QMHP), if not aiming to bill Medicaid)
o Peer support: Community health worker or peer support for coordinated care and case management) access to housing, clothing, food, and insurance
o Manager: background in mental health, business background (MBA or non profit leadership), experience managing people, program design and evaluation
Calls for service: PSR will be dispatched when a caller reports:
o A person who is possibly experiencing a mental health crisis; intoxicated and/or drug affected. This person is either outside or inside of a publicly accessible space such as a business, store, public lobby, etc.
o A person who is outside and down, not checked.
o A person who is outside and yelling.
o A person who needs a referral for services but does not have access to a phone line.
The call meets the previous criteria - AND
o There are no weapons seen.
o The person is not in traffic/not obstructing traffic.
o The person is not violent towards others (physically combative, threatening violence, assaulting).
o The person is not suicidal.
o The person is not inside of a private residence.
Cost: For FY2022-23, total budget of $4,830,760. As service expands to citywide capacity, they will operate:
o Three vans at peak hours in service Mon-Thurs (7:30 am - 10 pm)
o Shift to six vans, with two in evenings, after 10 pm
o Up to six teams with 58 staff at a total cost of $9.1 million
Outcome: Portland Street Response partnered with Portland State University's Homelessness Research and Action Collaborative <https://www.pdx.edu/homelessness/> to help provide external program evaluation. Frequent updates on program outcomes will be posted on the Portland Street Response webpage and will be presented to Council during and after the pilot. Portland State has released its six-month evaluation of Portland Street Response and you can access it here <https://www.pdx.edu/homelessness/sites/g/files/znldhr1791/files/2021-10/PSU%20Portland%20Street%20Response%20Six-Month%20Evaluation_final%20for%20website.pdf>.
Olympia Crisis Response Unit
o Two teams of two, with two leads. (Essentially two three-person teams) for 7 days/week, following PD 10-hour 40-minute shifts
o Just under $2 million to expand to 21 hours a day coverage (2022)
o CRU is on Police radio and using same dispatch center. By using same radio, all hear same calls; dispatch needed one set of requirements
o Transport from one public place to another. Mitigate situation. No good spot but this one isn’t good now.
How does 9-8-8 fold in? The new 9-8-8 crisis line is simply moving crisis call centers from a 10-digit number to a three-digit number so it easier to access and easier for those in crisis to remember. It is not a pathway for a city/county to start a mobile crisis response team nor does it have any funding for one. The state is educating call centers with the triage component so if you do have a MCRT you would know when to send it to them and when it wouldn’t be advised.
BACKGROUND:
This report is a response to a January 10, 2022, City Council request for information. The purpose of this report is to define what mobile crisis response is and how it works in most communities, summarize available resources here in Salem, identify gaps in the system and impacts of cost to cure those gaps.
Staff were tasked with identifying potential community partners (such as local non-profits, medical service providers, behavior health providers, local governmental entities), staffing, funding sources, cost of pilot project, potential service providers, hiring and training resources for unit personnel, outline of the continuum of related services currently provided, what it would take to expand existing law enforcement and qualified mental health professional Mobile Crisis Response Teams (MCRT) to 24 hours a day seven days a week, how a civilian-led mobile crisis unit would fit alongside existing public safety programs, and how this service may impact Dispatch and any associated staffing, technology and protocol issues.
Courtney Knox Busch
Strategic Initiatives Manager
Attachments:
1. Salem Response: Behavioral health emergency.
2. Central Lane 9-1-1 Dispatch workflow.
3. Portland Street Response frequently asked questions.