National Association of State Mental Health Program Directors



Please stand by for realtime captions. >> Good morning. You can press star six to unmute your phone line. At afternoon and welcome to today's seminar entitled Improving Access to Care using The National Guidelines for Crisis Care-A Best Practice Toolkit . This is sponsored by SAMHSA and developing the contract with NASMHPD. My name is David Miller from NASMHPD and I am excited to be with you today. I would like to thank all of you for joining us today. Before we introduce today's presenters, I would like to go over a few housekeeping items. Today's webinar is being recorded and the recording, along with the PowerPoint presentation, will be available on the NASMHPD website within 3 to 5 days. For participants only, audio is being streamed through your computer speakers with no need to connect by phone unless necessary, in which case the phone number is listed in the notes section on your screen. If you experience any technical different difficulties during our webinar today, please type a comment in the Q&A pod on the right side of your screen and someone will be able to assist you. Also, at the end of the presentation, we will have a Q&A session. Please use that same Q&A pod to type your questions for the presenters, and we will ask as many questions as we can today. The PowerPoint slides are available at the top of your screen where it says PowerPoint presentation. Just click on upload file to download the fights. He will have a short evaluation at the end of the webinar for you to give us feedback . We ask that you take a few moments to complete that for us at the end of the webinar today. Please know that upon request, you can send -- We can send you a letter of attendance for today's seminar. My Associates email address will be available at the top of the screen during the evaluation for such requests. I would like to thank SAMHSA for their leadership in making these guidelines and toolkit possible and their support in allowing us to share this information with you today. Again, thank you all for joining. Today's presenters are David Covington , CEO and president and behavioral health link partner of RI international. Commissioner Marie Williams from the state of Tennessee , Debbie Atkins Director of crisis coordination and developmental disabilities. On behalf of Georgia's Commissioner Judy Fitzgerald, but start us off today, we are very honored to have Dr. McCance-Katz , Assistant Secretary for Mental Health and Substance Use . We are pleased to have Elinore McCance-Katz today. I will turn it over to her to give a special introduction. Thanks very much and good afternoon everyone. I'm very pleased to know the level of interest on what I think is a very critical topic in our field. As you know, as I think you know, in my role as Assistant Secretary for Mental Health and Substance Use , I have been very focused on developing and implementing preventive systems of evidenced-based mental health care across states and within our communities. Crisis services and systems play an integral role in the delivery of mental health care. These services provide acutely needed care and they also serve as a very important entry point for so many people into the healthcare delivery system. They serve as a means of immediate mental health intervention I trained professionals and are the much more appropriate alternative to emergency departments that often are overrun with those seeking acute care for medical conditions and which are not prepared or equipped to handle mental health care needs. If implement it properly, these crisis systems also represent a societal cost savings with ED and law enforcement costs decreasing significantly as a result of the availability of crisis services. I want to ensure that states and providers are well equipped with the knowledge to develop such systems and services. That is why we have partnered with NASMHPD on this very important toolkit. Now more than ever we need to ensure that individuals in a mental health crisis have a safe place to turn and are not required to seek an ED as their only option because of a lack of crisis services tailored to meet the needs of those experiencing such mental health emergencies. SAMHSA is committed to providing resources where possible to the element of these resources such as our expansion grant programs and our recently announced emergency response grants. They can also be used to provide crisis intervention services. The successful implementation of a network of comprehensive and life-changing services could be excellent for Americans with a diagnosis or Americans without a diagnosis of a mental disorder but who find themselves in need of acute care. I very much hope you will find this toolkit to be of use and that you are able to utilize its principles to develop these valuable systems in your states and communities. I hope that you find this webinar useful and I hope that everyone stays safe and healthy during this very difficult. In our nations history. Inks very much. Thank you so much , Dr. McCance-Katz. With that, I will turn it over to David Covington with RI International. Thank you so much and thanks to the assistant secretary. Your leadership and investment and continued focus on action is making a tremendous difference, not only with these national guidelines, but also with the work that you and HHS Secretary have done around the IMD demonstration waivers, your focus on the 988 national three digit crisis hotline, and also the COVID-19 investments that you are referencing. It is these continued, persistent actions that are really making a difference. I would also like to thank Brian Hepburn with the national Association of State agile health program directors for his continued leadership and partnership with the assistant secretary and the work that NASMHPD has done . SAMHSA determined a few years ago that 10 million Americans were struggling with thinking seriously about ending their own lives. Even for those of us in the field, that was more than we anticipated. Millions more are struggling with substance use, mental health crises, and of those individuals, many find support and help in peers , friends, coaches, pastors, colleagues . Others , their strength, their supports come other resources, are not sufficient. Even though they are concerned about the consequences, they or a family member or a friend out reached for help. 20 to 25,000 every single day in the United States and up in a hospital emergency department for these concerns. Many of them arrive there on their own or with family, but many more are brought by police. In 2016, the national action alliance put together the crisis now policy paper. I partnered with Dr. Michael Hogan who come a many of you know , spent 25 years as a state mental health Commissioner in three different states. Mike wrote this in that report, crisis is limited , and after that . A workaround. Even nonexistent. In many communities, depends on after our on-call therapist or space set aside in a crowded emergency department. It's fragmented. So, despite the 20 to 25,000 people per day, his knees were so desperate that they end up in a hospital emergency department. Despite the fact that from the beginning , the framework, the architecture for community mental health included crisis as one of the key five pillars, it just never received the action or leadership or prioritization or funding that was required. It did not have the national guidelines to guide it in a way that it would become what it needed to be. Now, for the first 60 years of that and even predating community mental health, we had our first crisis hotline, still operated in Los Angeles . It started in 1958. Over the decades , we thought individual counties or states, usually a county or a city or a component of a system , decides to try to do something innovative. I am not going to go through all of these. But if you were a crisis junkie, as Debbie Atkins and others have been , you over the course of time likely visited some of these programs to try to learn about the innovation that they were working to do. But these efforts were generally not scaled up or, if they were like CIT out of Memphis, it was only with components of the system , working with law enforcement, but lacking the innovation to emergency receiving. These were efforts, but they do not have large-scale impact at the level that we needed. By 2015, the issue was reaching a new level of impact. The vice president of behavioral health for the California Hospital Association, representing over 400 facilities across the state, and she wrote this in an open letter about this challenge. I will draw your attention to the first sentence and the words in red. The practice of those 20 to 25,000 people per day going to the hospital emergency room for the beginning of their triage into crisis is not appropriate, not safe , and not an efficient use of dwindling community resources. It was about 2005 when we started to see not only these issues with the chokepoint of sending everyone to the hospital , but a number of other challenges begin to rise to the level of state leaders. The Supreme Court ruling in Washington state around psychiatric boarding and the extremely long waits in hospital EDs . The Seattle Times that a year-long investigation in which they found an average weight of three days. Not three hours, but three days for individuals seeking a referral to mental health or substance use in a hospital ED. The cost of an extraordinarily inefficient and ineffective approach, as well as concerns about public safety -- There had been a number of episodes of violence. While this is a complicated matter, the public's response and certainly the politicians response was that we had to do more around public safety. Then, this issue of the depths of despair, the tragic outcomes of opioid death, alcohol-related deaths, suicide deaths come a and a host of other outcomes coming far too often and common for anyone's -- Just rising to a level we cannot contend with any longer. In Washington state, after that Supreme Court ruling, that psychiatric boarding, as they refer to that practice, was unconstitutional, we saw a significant investment. California started legislative efforts and had a dedicated website around their belief that 70% of individuals presenting in emergency departments for mental health or substance use would not be there if adequate crisis continuum and court triage services were available. It was really work in Georgia, Arizona, and then Colorado, that pressed us forward for the potential of what could be. In 2013, Governor Hickenlooper and the Colorado legislature , after the Aurora and Columbine tragedies, started to reflect on what they could do. They did an environmental scan nationally, the Department of Health, studied the work being done in Georgia with the air traffic control model of a crisis call center hub, and the statewide crisis for all 159 counties going to rural areas, going to where the person was. He looked at the facility model in Arizona, where law enforcement bypasses the hospital ED and goes directly to a crisis center. They put together the most comprehensive continuum in a set of RFPs for the entire state. Not only for frontier areas, but federally designated, not only for rural, but federally designated frontier areas as well. It put forth an architecture that would include all of those elements. In 2016 , we saw the Crisis Now report in partnership with the national action alliance and a host of leaders from around the country, both policymakers and researchers as well as crisis providers and individuals with lived experience and family members who came together to look at what Colorado had done. It was also to reflect back to the original crisis monograph that John O'Brien and the technical assistance collaborative did back in 2005 , which really became a Bible, if you will, for many in this particular space. John will tell you, even though they reflected and contemplated at that time going as far as the assistant secretary has gone with these national guidelines, they decided the timing was not right and that was too much to take on. They certainly laid a foundation. The work that NASMHPD has done over the last several years persistently prioritizing crisis as the number one area for real and tangible impact on people with behavioral health challenges has really set the stage, for now, the work that local innovators have done -- Again, these are not comprehensive list . There are many states and many local areas that are not included in this PowerPoint that have tried different innovations to move the ball forward and now to see all of that coalesce into a national effort is really a tremendous breakthrough. Now , Paul, why don't you just give a little bit, Paul, of where we are going to go with your section and then I will come back. Lay the groundwork, Paul, with some of the areas that the NASMHPD team and we worked on together as being core challenges that SAMHSA would want to tackle in these national guidelines. Thank you, David. So, when I joined the team a couple years ago, I came from being an assistant director with Arizona Medicaid. Within that framework of working in a Medicaid program, we learned that structure matters a lot. So , I started engaging in dialogue with other state , counties, communities across the nation, that were requesting support bringing up crisis care. Often what they were looking for was some incremental development of access to care in their crisis system, and most have some form of crisis provider system already in place. When you looked at it, when you looked at the structure that existed in those communities, the truth is you are surrounded by very well-intentioned providers. You are looking at state leaders that wanted to get real-time access to care when and where people need it. But the structure was simply not there to do that very thing. If I reflect back on my time at Arizona Medicaid, the director at the time would discuss how you have to create a system that could support the needs of the community. That structure really mattered a lot. I think they are carrying it forward and that state currently. When I would get to the communities, I would see, for example , that there would be mobile response teams that wanted to get out and see individuals in the community . In fact, their reimbursement rate did not support them actually leaving anything other than an emergency department to do psych consultation at the time. Providers that were very interested in creating facility based crisis services that would accept people in real time functioned very much like an emergency department would for physical health and simply couldn't do it. What this group did, for my perspective, is they advanced a definition of crisis that had not existed previously. David, you went over 70 years of crisis system evolution, but with all of that, we never had this strong definition that has been advanced through this partnership with SAMHSA and NASMHPD to say look, all services in the continuum matter. But crisis services are the ones that serve any person, anywhere, and anytime. So with that in mind, what you are going to see here is a design in this toolkit that allows you some guidance on how you would reimburse for services like that, how you would license facilities and programs to deliver those sort of services, and you would have actual billing codes dedicated to that work. Until you clearly define what the roles and responsibilities are of crisis providers, though, you are really not positioned to do that. Right now, what we have seen is a broad range of different types of services that fall into this crisis realm. If I click through here, we are looking at quite a roadmap of finding what is crisis care and how do you connect. There is actually a model that we can call upon. In the physical health world, we have a model that is being used. There is a 911 number that is called when someone is in a physical health emergency. They answer that call no matter who was calling. They do their best to assess the needs of that color and then they connect them to care , and that could be fire, it could be ambulance, it could be police. The other option you have is to connect an individual in that emergency system to an emergency department where they will say yes and bring each person in. There is not too much for that department, they will bring them in and they will provide care. We do believe that there is an opportunity to do that very same thing for mental health and substance use crises. When you are seeing here on the slide is actually, although there are tend, tend to find service categories, there are really a dozen of them as we combine some in there. They are all important for my perspective. Those include crisis navigation and warm lines. It includes clinical answering services. It includes 24/7 outpatient. It includes things like programs, crisis residential programs, all of which matter to a community and reduce the burden on emergency departments. They reduce the burden on the justice system. They are engaging people in care. However, when it comes to the three services that we have to find as true crisis care, the ones that should warrant specific coding to ensure that you have a resource for your community , we went with the crisis call hub that you will see defined here and we will get into some of those details in a bit. But for those individuals, much like 911, they answer every call. We have seen movement towards 988 being an option for mental health and substance use crisis in these country. Until we have those, we have partners at the suicide national prevention high hotline. We have good examples functioning statewide and a multitude of others around in our communities. They are delivering that very service. They are answering the call every single time and they are connecting people to care. We have mobile crisis that goes out into the community. So, those individuals go to wherever you are and whenever you need care, and they deliver that care. So, going back to that earlier discussion. Unless we have specific coding and reimbursement to support that, much like fire or ambulance, if we don't do that and support capacity in a system of firehouse type models of care, then those providers that are very interested in being that resource simply are not adequately funded to do it at this point in many communities. Then we look at the crisis receiving and stabilization center, which is number three there. Much like an emergency department, these programs say yes to every person that comes to their door, whether they come in the back of a police car, they come through fire, ambulance, family refers them, or they walk in themselves. The answer is yes, you can come in and we will offer care to you. These are very unique services that we believe , and you will see defined in this toolkit, represent the three essential elements of a crisis system. We start talking about how you bring those to life and that is what this toolkit is really about from my perspective, David. It is offering access to these very critical services without in any way saying those others are not important. Of course they are , but true crisis care requires a narrow definition that allows you to structure reimbursement so that service can be delivered. That way those in your community are no longer faced with going to an emergency department or into a justice system because access to real-time care simply doesn't exist. The human impact of such an of roach, the clinical effectiveness of that, it is not hard to get to. But for a quick moment, let's make sure that we revisit the cost component here and the throughput, if you will, or the numbers. So, most of our communities, historically, over those 70 years have been really based upon almost a light switch model . With each individual, if the light switches up they need acute care and we will grapple to try to get them into a program somehow, somewhere. Or, they do not need that care and they can be supported by an appointment into outpatient services of some type and aftercare or an outpatient referral for an evaluation with a clinician and hopefully to see a psychiatrist. The reality is that, again, the continuum of care is much more of a series of steps as opposed to a light switch, and the LOCUS gives us one tool to think about that. Here is a framework with six levels. If we look at those individuals again , back to the 20 to 25,000 per day nationally who hit the emergency department, let's not talk about anyone else for a moment. It just them. Not those who call the crisis line and had their needs satisfied in that way or supported in that way or got help from a peer or a coach or a pastor. Instead, just those that were in the hospital ED. We did a 10 year survey of almost half 1 million records of people who met those criteria. They were either served by mobile crisis in the community , they were in the back of a police car, or they were served in a hospital emergency department. This is statewide data for over a ten-year period. They all had a LOCUS score . The shocking finding is that 4 out of 5 were not in that class that we talked about with the light switch, either needing acute care or outpatient care. Almost , over 80% of them actually needed a level 3, 4, or 5 , most closely aligned with those three services, Paul, that you just referenced. What we have done, that 20 to 25,000, actually comes from work that we have built upon assumptions that came from not the John O'Brien, but the John Snook tack. And some of their work, thinking around the number of beds that individuals need, we built on that for the number of individuals , again, meeting those criteria of core community crisis flow. It has held up pretty tight across multiple states looking at this model of 200 persons per 100,000 population per month. So, for every 200, that is about 8500 per month in the Phoenix area because of our larger population. But for every 200, we are going to have 108 who are in that locus of a five and that 23 our temporary observation and treatment is the best place for them to start. We prefer for them to be seen by mobile crisis first. Paul, why don't we begin to have you take us through those three services and how the SAMHSA guidelines defined both the minimum expectations and best practice targets. Perfect. The other thing I would say as we jump into those is that nomenclature matters a little bit here. This can get a little confusing. So I am going to do a little bit of disclosure on our own programs. We do operate warm lines at RI International. We have 24/7 call services for those we support in our communities across the nation. We also operate crisis residential programs, respite programs that we call crisis respite , and the truth is I think every single one of those services is really important to the communities we serve. However , I am going to explain why they are not crisis services as we lean into this a little bit for my perspective now. Let's consider a crisis residential service as an example. If we operate a 16 bed facility with an average length of stay of two weeks, it could be one week, whatever you have. But if it is two weeks and we do the math, that really means we would, on average, admit one individual into the program per day. All right, one discharge, what admission, gets his 14 and a two week period. So roughly, that is the flow that you would see. If we are expected to be a crisis receiving center, let's be honest come away number 17 shows up, there is no bed for that person. We cannot take them in. The answer becomes, no. The emergency department cannot say no because we are full. When we are contemplating this concept of real-time access that avoids people going to an emergency department or the justice system, it is because our partners that are first responders now can bring someone in and they will get care immediately. There's no question about that. It is not are they fall, is there capacity. This is not in anyway reflect negatively I hope on those operating community respite programs. What it is saying in these cases is that they are not truly crisis services because we cannot take the capacity we do and other programs. So, the example of our crisis receiving center, I think we had 25 admissions into our programs in Peoria yesterday. That reflects an ability to really have a true Safetynet resource for that community. In fact, over 80% of those individuals typically come through the back of a police car. So we are saying yes to everyone regardless. When it comes to the three services, this language actually was initially brought to my attention by Anita Everett at SAMHSA . Someone to talk to, you need someone to come to , which are the mobile response teams that come to wherever you are when you need it. And, you are looking at a someplace to go, which is a crisis facility that says yes. You will see, this looks a bit different than if you had beds in this unit. It is really a Living Room Model for engaging in dialogue and assessment that allows you to serve a large amount of people in your space that is really not possible when you have beds with an average length of stay of several days or weeks potentially. You simply cannot say yes every time when someone comes in under those structures. So, what SAMHSA did in the toolkit that I find really important is they describe the minimum expectations for each of these core services and they went on to fully align and raise the bar the best practice pieces that go into each of the services. David, do you want to talk through a little bit of what distinguishes these crisis call hubs? Too sure, Paul. The crisis call center hub is definitely 24/7 availability and not a triage that we are checking for insurance and you call this number or a different number. I think 988 is starting to press forward hard into the availability of such a service nationwide , that includes clinical oversight, uses best practice assessment of suicide rest, it is really integrated, again, this error traffic control idea with the larger healthcare system in this more sophisticated model where you have mobile teams going out into the community that there is a triage and assessment and connection using technology to guide those. The technology is really just a support to the principles that when someone contacts those numbers, they are putting their hand in the hand of the individual at the call, chat, text line . They are keeping that hand until they safely connect them and assure that connection with another service. Then the, raising the bar is, again, using that technology, caller I.D.. We have a system today where the lifeline routes based upon the area code. It is really beginning to move into much more sophisticated areas that are being contemplated with the 988 platform and moving to the dispatch of mobile teams by GPS using electronic bed registries to ensure the inventory of those various programs can be seen. Scheduling into outpatient programs electronically, raising the capacity for what we might call valve management and really ensuring that resources are used for their optimal level and that anyone, anytime, anywhere, is the focus. When it comes to the mobile crisis peace, David, there is mobile crises happening around the country. We are going to typically see that clinicians are involved in the response. They are doing quality assessment work there. But what we are asking in this case is to say there is a difference between doing a psych consult in the emergency department and doing a community-based assessment. This is really pushing on this view that we have to get reimbursement right. I actually have not run into a mobile crisis provider that does not want to go out into the community. They absolutely want to keep people out of emergency departments. They want to deliver quality care when and where someone needs it. However, if you use, if you call any mobile response, mobile crisis, using the same coding, and you can all envision this as you are trying to find services, going to an emergency department where I have 10 people lined up and do a psych consult is different from driving from this part of town to another part of town and even having availability for when the call comes in in the next few minutes. So we are really talking about 24/7 support to be a mobile crisis response provider and get to the best practice, we need to have peers involved in that response. So we have the clinician partnering with a peer that is out there actively engaging the individual in need. And we are using technology to make this the most efficient possible process. When you see GPS enabled technology in there, that is really connecting with this crisis call center so that together you are serving the community. Lastly, it mentions engaging police as a last resort. What we are seeing , and there is a fair amount of this out there. In fact, we operate a team that is a co-responder model. It is certainly a step in taking the burden off of law enforcement to operate as a factor mobile crisis teams. However, ideally, we are keeping law enforcement out of the interaction when the mobile team is out there whenever possible doing that work independently. The way we get successful at this, of course, is we create funding mechanisms that support multiple mobile teams being available in a community based on the needs of the community. Again, the firehouse model, so you're going to have to have some resources waiting for the next call , and efficient dispatch through that crisis call center hub, so you are doing this as quickly as possible. You are really getting people into care. All of this is meant to say, you mentioned the treatment advocacy Center work, David, and, you know, what they shouted out many years ago was to say look, it is not okay that individuals with mental health and substance use crises are being incarcerated at disproportionate rates to the rest of the community. In fact, exponentially higher than the rest of our community. It is not okay that they are taken to emergency departments where they are boarded and waiting for care for hours or days at a time. It is an unacceptable scenario. What we need is a facility that says yes. This is a whole different thing and I think, you know, I don't know what you call it. Different communities collect different things. What we see in the guide here is that we are calling this a crisis receiving and table is Asian center decided to say yes. You will see guidance on how you would license that. This digestion is that you use chairs instead of beds in these sort of programs , much like an emergency department has chairs out there for individuals. You can see these are a little more open, welcoming, engaging environments than your typical emergency department. It is designed to say that there is a place individuals can go to get care when they need it. I do not have to wonder, can I get in. I do not have to wonder if a that is available. Will they be a bed available tomorrow. Law enforcement is not thinking, do I have to sit with someone in the emergency department for hours at a time . Should I book them into the justice system for this minor offense that put them in the back of my police car? Can I see pretty clearly, these are a lot of crisis intervention trained officers, we want to get them care , we just can't dedicate the next 12 hours of our day to making that connection happen. In fact, what you will see as many crisis providers that are operating and whether that is RI International's work , we track those times. It is important to us. Our funders track those times. I believe we were at two minutes and three seconds was the average law enforcement drop off time for the 400 referrals we received in Peoria last month. Those are really important to know. Please are wondering will we say yes, even in the midst of COVID-19 challenges , the answer is yes. We figure out how to do that quickly. So the minimum expectation with you say yes, but ideally your best practice is that you have a dedicated first responder area so you create really strong partnerships to see people quickly. You create intensive support beds. We all know that flow is a challenge in any community system. In fact, a good crisis system annex with that polar continuum which includes crisis residential services. Those short-term residential options for individuals. Respite options for individuals. A strong outpatient partner so we can have them off. If operating with this capacity of chairs is going to be license where you cannot serve someone for more than 24 hours, so you need to have beds that you can get them into when the need is there, whether that is your own, or you have created partnerships in the community. David, do you want to talk through our Core System principles? So, Paul, Jess and the remaining five minutes that we have, the guidelines do go into the integration of recovery needs. You already referenced to some degree the significant role of peers in this process. The integration of trauma informed care, the utilization of zero suicide and safer care, best practices, and a preeminent focus on safety and security for all. I think those are the areas that providers and funders are the most thoughtful about as moving in this direction when you think about mobile teams going out and seeing someone under a bridge or going to the apartment or a home out in a rural area. Those safety concerns , and those are spoken to in the guidelines, as well as the pivotal relationship with first responders. Of those mobile teams are going out without law enforcement or ambulances. Again, unless law enforcement or an ambulance are required. Because of a clear-cut medical or public safety concern. Then, just, quickly, the guidelines go into this integration or fusion as we call it, a combination of a much more open and the kind of environment that we ourselves or we would want our mother to be served in that includes peer staffing and peer supports. A welcoming, engaging focus, but also, has this rapid, direct access. Again, more in line with what we historically would have thought about the hospital. Our most crisis talk article this year came from CIT internationals director Ron Bruneau, mental health should not come in a law-enforcement car. Mobile is doing that. But the reality is thousands of times per year in our current system, that is the way people first see the engagement. There is no 988 in place yet. Individuals are calling 911 or family are doing that. Law enforcement is the first contact. For those situations that we are giving law enforcement as an option, that is not where there complement cotton plating hours of what they call wall time in a hospital or booking the individual on some nuisance crime. Instead, giving them the direct access to a crisis receiving facility . That is the language that Sam Cochran used almost 40 years ago when CIT was first put out , in the very first version. A model where a crisis facility is a 23 hour program that you were talking about, Paul, where there are zero rejections, zero hospital visits first unless there is a clear-cut medical situation like the person is unconscious or there is some immediate demand. Otherwise they are simply going to the closest available center and there is a quick turnaround for them to get back on the street. If there is some kind of medical or other kind of issue going on, the crisis provider is taking that on. Again, the best practice is this dedicated entrance. You see an example here from our Peoria facility where they go in and it is a trauma informed care setting. It is a quick place where a peer or nurse practitioner or physician can connect with them and make an initial integration. So, we have put all of that together in the, as NASMHPD and SAMHSA have worked together on these real tools. Paul, do you want to speak about some of the specific components that folks can use to see how they build the mechanics for this? There are a number of sections in here that are important. It includes funding your crisis system, how you would do that, and you mentioned some of the cost. When you think of state structure, you think of where you are paying now. Let's talk about mobile teams as an example. If you do not have mobile responses where individuals naturally go when you do not have crisis facilities is they are going to go to the emergency department. The average bill that I saw published recently was $1233. The truth is, finding a mobile team adequately that can successfully resolve 70% of their calls in the community is going to cost far less money than that . You are not even asking to push out more funding and most of these cases. You are asking to use funding differently and services actually cost you less to get better care and better experience for the person. What we have on the toolkit itself is you are going to see reference to this staffing calculator, crisis agility staffing calculator. You're going to see the crisis resource need calculator for communities which assesses the cost of care. It protects the number of mobile teams, crisis beds are chairs that would be beneficial, as well as acute beds in the community based on population size and a number of other metrics. These are all posted on the NASMHPD website , . There is a tool there in the top right that allows you to access a number of resources. It also allows you, if you navigate in their little more, see some of those #CrisisTalk articles that are out. And also this paper that we are seeing , national guidance for behavioral health crisis care, best practice toolkit. We have gone through some of the standards for each service itself. It also goes through specific coding recommendations. It is a recommendation that you restrict coding use to those true crisis providers. It would mean potentially evaluating, if someone else is using those sort of codes in your community or your state, finding codes that work for them, utilizing modifiers and other things. Again, we would be happy to help in partnering and evolving some of the solutions. But I believe the only way you can get to truly funding a crisis system is you have to recognize the unique characteristics of saying yes for all of these providers and going where they need to go. Therefore, you can fund that service. Once you have other types of providers using the same coding , it becomes very complicated. That includes a complexity around those partners contracting with commercial insurers and others that often look to state published rates as a baseline for how to find this care. What we want to do is reduce the burden on the taxpayer, on state and local communities, by getting everyone to pay their share, which would be enforcement of parity. This is a big step towards getting there. It should be noted, a lot of what we had talked about today did focus on adult system. We did not talk about the LOCUS for kids. We also know there is a difference between a 14-year-old child in a 3-year-old child for how you do care. There are complexities in designing the systems area but the experience and the expectations should be the same. It should be that children that have acute needs get them addressed through a system . Again, you will see a path in this toolkit that allows you to figure out how you can fund these, what it would cost, how you establish rates, the coating that is possible that actually creates a roadmap that, after 70 years of crisis system evolution, is finally here. I admit that I am a huge fan of the SAMHSA, NASMHPD team that contributed to developing this. It is really saying enough is enough, we have to offer real care in real-time to people and we have to create a system and a structure that allows us to do it. I believe that the toolkit offers that us. None of that happens without it being pushed forward in states like Georgia, who has done this both in rural and metropolitan areas for both adults and children and people with mental health, substance use and IDD. This is a great time to transition to Debbie Atkins, the director of crisis coordination there. Thank you Paul and David. Good afternoon. I bring greetings from George's Commissioner, Judy Fitzgerald. She really wishes she could be with us but unfortunately we have a pretty serious COVID-19 issue that needs her attention today. As the crisis junkie that David called me, I was asked to show an example of how technology and data can help you manage your state system. The Georgia crisis and access line, or AHCCCS as we call it is a function of our collaborative ASO. AHCCCS creates an infrastructure for managing the Georgia crisis system . The next few slides will list out in detail the main functions and how it helps us is our system. So they have five main functions. We have a call center which David has to strive and it manages a large volume of crisis calls every day. They also schedule urgent appointments for all of our out patient clinicians. They answer the locator calls for Georgians and they answer 100% of the national suicide prevention line calls that come from Georgia area codes. In January of 2019, GCAL developed the app that offers text, chat, and call features. This was designed to attract a younger population who would not traditionally reach out to the traditional call centers. GCAL is the single point of entries for people in the state of Georgia. And we do have statewide mobile crisis access. In 2012, the behavioral Health Link, in a partnership with DBHDD, develop a real-time pet management system where the providers and DBHDD can see who is waiting for a bed, who has a bed , and those who have clearance, the names of those individuals being served. All the data from our GCAL system is published into dashboards and raw data that allows DBHDD to measure success and weak points of our system. This is a picture of our call center. This can become completely remote in a very secure way during emergencies. National disasters like COVID-19 or hurricanes that frequent our states have at times caused us to remove remote. This is a really great feature that we have. The GCAL system allows 24/7 outpatient scheduling through their web-based scheduler program. This is for urgent and emergent appointments. All of the outpatient providers contracted with the state of Georgia are required to give AHCCCS electronic appointment sides or to have just-in-time scheduling for appointments. This slide kind of shows what the schedule looks like. Choices appear in order of preference based on a customizable logarithm that considers provider location, distance from the individual, demographics served such as age or presenting problems, and who has an appointment available. All takers can place on an individual in an appointment slot anytime of day or night and when the provider opens the next day, they open the application, they can view who is scheduled and they can download all the clinical information that they will need for that appointment. This is a picture of the app. You will see that it is offered through Apple and Google platforms. The individuals who use the application have choices of texting my chatting connecting via phone call. In the past year, Georgia has seen the app grow in popularity with our users feel comfortable this day and age connecting electronically versus three telephone. As we mentioned, Georgia requires all of our mobile crisis teams to be dispatched to the call center. We have statewide mobile teams that include peers on our teams and GCAL can track mobile crisis team locations statewide. This is a picture of the dashboard. Call takers identify responsible teams based on the location of the individual in need . Once they click dispatch, the clinical triage is sent via an encrypted email to the team. Through this system we can measure transit times, response times, time on the scene, and outcomes of the visit. We can see teams by regions, multiple regions, or even statewide data in real-time. Clicking on the individual case brings up the clinical data from the call center that was collected for dispatch. Next, we actually have a picture. It shows multiple teams in our metro area. It shows where those locations are. So, the live monitoring system, Georgia has a system for intensive referrals for inpatient care. It is very different than traditional point in time dead registries. We actually can see who is waiting, how long they have been waiting, where they are waiting, all in real time. Let me say during the COVID-19 crisis, this has been a lifesaver for my position. This is an example of a screen showing the cases that are pending for intensive referrals in the state of Georgia. By clicking on an individual's episode, it brings up live information on the referral process. It reduces the amount of telephone calls between emergency rooms and receiving facilities and it allows the receiving facilities to be able to accept with little contact. So, as part of this referral system, we also have a bed inventory tracking system. DBHDD can see all the inventory for state-funded beds and state contract beds. We can see them in our crisis stabilization unit and our state hospitals. This is an example of the bed inventory. It is a summary sentence. It gives us the status of every bed in the system statewide. It can be sorted by regions and status , such as being available, out of service, or occupied. We can see who is in the bed, why they were referred by their diagnosis, if they are voluntary or involuntary, or even how long they have been there. This has been a lifesaver for me in the last little bit of time. So this is a slide that shows this is set suggested data points that are listed in the best practice toolkit. Georgia has most of these. We admit that we are working on adding the few that we currently don't collect. Other states such as Arizona have mentioned some of the police drop off times that are in their contracts. Those are a few of the things that Georgia is working on. The following slides are going to show you a few examples of the dashboards and the reporting functions for Georgia. So, just about any element tracked in GCAL can be pushed to a live dashboard. Currently we have live dashboards internally for call center metrics and externally facing dashboards for mobile crisis performance statewide. The most current data listed on this slide are key performance indicators for the crisis units in Georgia. Through our TTY grant we are actually working to have these data points published into an internal dashboard and then eventually an external dashboard. This is an example of a mobile crisis dashboard . We look at response times and assessment times. These dashboards can show a particular region, or we can look at the whole state. This is a screenshot of an internal call center dashboard from GCAL. It tracks performance metrics such as speed of answer, abandonment rate. It gives BHL the information that assists them with call-center workforce planning, let them know times of day where things trend high, and how to do that. Lastly, this is a slide that shows an example of some of the data points that we have extracted from the GCAL system that leads to reporting management for our crisis system. This is an example of a length of stay report for some of our crisis units and a recidivism report. So all of this data really goes to help us manage and drive where we place new crisis systems, how we fund our crisis systems , and I hope this inspires you a little bit to think about ways that you can use electronic platforms and data to drive your system. I think now, Commissioner Mary Williams from the state of Tennessee, is going to talk a little bit about funding. Thank you so much for that. It is very much appreciated. Aren't we very fortunate in our state to have the leaders that we have with David and Paul and Judy and Debbie , as well as the people from NASMHPD who have really been guiding and leading us as well as the leadership from SAMHSA. I have been asked to speak about the history of crisis movement here in Tennessee . It is interesting, you will see on the timeline that starts in 1991 . That actually is where I started my work in 1990. I was fortunate, very fortunate to have been in the city of Memphis where Sam Cochran was starting with his CIT model. Many people know him, but they do not know the president at that time in Memphis, an unbelievable woman. A firecracker. What really started this was a police shooting that had occurred and a beloved member of the community who was shot. Sam got together with the national alliance for mental illness with Helen and actually got together with the mental health center that I worked at, Midtown mental health center. What you will see is that we actually had the first crisis stabilization unit in a state of Tennessee at Midtown. I am so grateful for the history and background of being in this field and being called to serve and being allowed to serve and to work with Tennesseans that are set struggling with mental health and substance use issues. I have been in that area and feel Census time. What we did, as we move forward, you will see that we contracted with 13 providers across the state to deliver mobile crisis services so that every county in our state, we have 95 counties, every county, every member had the ability to access 24/7, 365 days per year, mobile services. We had a statewide hotline number that still exists today. One number, one line, and then it gets routed to that local community provider who response and immediately takes the call and starts working on how to respond to that particular crisis. That has been a really great model for us because we believe in this state and local accountability and local control. We do not have county boards like many have that we do all of our contracts direct with the community provider. You will note that we are very proud to participate in the national suicide prevention lifeline that we have in addition to our crisis call line , six providers that assist in answering the calls across the nation. Then you will note that our respite services were established in 1992 and it allows a community-based option that really offers a temporary reprieve from what is going on with that person with that family so that we can respond in the best way possible. As time went on, we expanded. You will see that where we are today, looking at last year's data, that in this last year we took 124,878 calls . Again, those are calls that came into the one line and went directly to that provider in that community. You will note the breakdown between adult and youth. You will see that our main thing is to provide the right treatment at the right time in the right place. We are very proud of our ability to serve 58% of Tennesseans that calling to serve them in the community with that full array of services in the continuum that we have. You will note that we added, I am very proud of this, crisis walk-in centers in addition to the crisis stabilization units that were put in our state. You will note where all of those are in our state , Memphis, Jackson, Nashville, Cookeville, Knoxville, Chattanooga, Johnson City, and Morristown. About 25% of face-to-face assessments are occurring there. They are open 24/7. When you come over , you will see it as it relates to our timeframe, that most of our face-to-face assessments from the call to the person going out, the duty assessment is done within two hours. Typically around 50 minutes. You will see that 79,000 out of that original 124,000 calls were done face-to-face and the breakdown that we have there. Our state has opted to have separate used mobile teams from adult teams. I know that some states blend, but we have them separate . If you look at our funding model , and this is something that is really incredible in our state, our statewide crisis hotline is funded with state dollars. However, our mobile crisis teams are funded through a very unique partnership with Medicaid. We have had a long standing relationship with them and they base their rates on a model that is determined with the Tenncare dollars that they have. For the mobile crisis, our total is right around 26 million. You will see the majority of that comes from Medicaid and we pay the remainder. He will look also at respite where the state pays at no cost or at cost not to exceed 1/12 of the total maximum liability. You will note what Tenncare pays for that total being right around 670,000. When you look at the CSU walk-in center, the state pays a portion of that as well as Medicaid paying another portion. The total of our services being right around $45 million to provide those services across our state. I am so proud of our providers because I know other time had we been as tested as you all have as well during the COVID-19 crisis. We are doing three days per week calls. We started out with daily calls with all of our providers because, as you are, we are dealing with limited PPE . It is pretty amazing to see these front-line workers that are struggling to know if they are going to have PPE for the day to go out and actually do what needs to be done to provide services in our communities. With that, I will and by just saying , one him that is come to mind multiple times as we have dealt with this, it is very important for all of us is we work in the crisis world is one that is called, it is well with my soul. And I will tell you that being a part of this tremendous group of people, all of you that are on the line , that everyday are coming in and doing work to serve people struggling , it really creates a space of it being well with our soul. It is my prayer and hope that you remain well in your soul and those that you serve and those that you love are protected. I will turn it back over to the moderator. >> Commissioner Williams, thank you. Thank you to all of the presenters. For those of you who have questions, we have several in the queue, but if you have a question for any or all of the presenters, you can type it into the Q&A box down on the lower right-hand corner. I will take the first -- We've had several questions around children and using this guide for children in crisis. So, David and Paul , we wanted to talk to you about , there is one comment that LOCUS is an adult focused tool. What are the recommended tools for early childhood and children in adolescence. More than that, tips and guidance on how to use this guide for children in crisis services? Paul, do you want to jump in on that one? Sure. You are right. When David showed the analysis that we have utilized to estimate crisis service need in the community, we did that based on LOCUS data over a decade. For children, it was not done during this analysis. But you would use Cal LOCUS or Cassie. It would depend what data sets are available to do a similar thing. The bottom line to this is the toolkit says that we should offer real-time access to phone, mobile crisis, and facility-based care for everyone at all ages. There is a smaller section that talks about rural and frontier approaches . Children are also very unique. This does not give you the provider design information which would say if I were designing a crisis facility for children and adolescents to say yes to all of them, I would probably need specific space based on the unique needs of those different populations. So , it does not go that far from my perspective, but it does go far enough to talk through the coating. If we get back to the key question here, anyone who looks at children or looks at paying at the services knows it is remarkably expensive what we are doing now. There are some kids with their unique needs such as those on the autism spectrum as well as those with developmental challenges that sit four days waiting for care. They are not connected efficiently. So, I do want to go back a little bit to the funding part of how this all works. So , if you think of the model of reimbursement that I am encouraging you to structure into your states or into your systems that you work with, what I am suggesting is that 96% of individuals we serve in our crisis facilities around the country never go to an emergency department. They do not need to. They are here for mental health and substance use crises and we are 24/7 staffed with medical professionals, nurses, nurse practitioners, psychiatrist, that are there to do the work. When you start thinking of reimbursement, we should not be settling for reimbursement that is half of an inpatient rate. You couldn't possibly pay for those services. In fact when you pay for them at a rate that is commensurate with what you would see for inpatient programs, you're actually getting real-time access to care for you are avoiding the initial emergency department clearance that often exists which is 1233, you are avoiding any specific ambulance transport to now get them to a care provider. You are actually just connecting people. So, using similar rates actually saves the system money and it is far better for your community. Although there is not specific guidance on how you would build the facility itself and their unique parts to it, I do believe it has a conversation in there which suggest how you should negotiate structures of rates per unique population. We know it costs more to do that work, but we also know it saves by having that resource in place. Paul, I think we should also add that while there are exemplars on almost everything we are talking about here across metropolitan and rural, across states, across providers, you have got mobile crisis team's going to the community in Arizona Terrace, outlaw Frontera impacts , half staff, have been doing thousands of these per month and seeing toddlers. They are trained for the situations where someone may have been in trauma and abuse. So , kids related to the call lines, kids related to mobile crisis, there are all kinds of terrific examples out there. Marie was referencing kid teams in Tennessee. We are not aware of great exemplars yet for the facility-based component of this for kids. It absolutely can happen . These principles are right there and can be applied across, but that is territory that someone is going to have to chart into. >> David, this is David Miller again, the moderator. I will also add that SAMHSA and NASMHPD teamed up last year on part of our beyond bed series and there is a white paper on our website that SAMHSA funded on children's crisis services. So, if you navigate to the NASMHPD page, you can find that as well. We have a question, again , to David and Paul , is there any data on how often mobile crisis teams are able to avoid an admission? I love that question. I saw that in the list, David. Two things I want to say about that. The first one is that when the national suicide prevention lifeline began to really advance in partnership with SAMHSA, the national network of crisis lines for 50+ years they were disconnected. In 2000 and they began to come together under the national umbrella of one 800 suicide. Then in 2005, the partnership of NASMHPD, lifeline, and SAMHSA took everything to an entirely different level. One of the most significant components was researched on by Medlin Gould and John. He is now deceased. But Madeleine Gould at Columbia University has continued to do this work for 15 years running now. One of the very first things she did was study the impact of the crisis call center. Not mobile, but crisis call center on outcomes. At the time, the mentality was that call centers were really information and referral. They are just triaging and connecting through the individual to care. Well, what she found was the most significant reduction in distress did not happen from the referral when she followed up with people weeks later. It happened during the call. During the engagement and collaboration with that professional. We find the same thing with mobile. When mobile goes out and takes the time to explore what has worked previously, what the assets and strengths are, what the resources are, begins to work through -- Barbara Stanley crisis safety plan for one example, when they do that work they can have a phenomenal outcome. What I will just reference is there are two different models out there. Typically when states are contracting for these kinds of services, the teams out there across the country are using the phrase hospital diversion as their primary metric. They are talking about speed of response. But hospital diversions as their primary metric and then does the percentage of individuals, the numerator out of a denominator, the denominator being everyone they say. The numerator being how many they can keep out of those acute care. And it is realistic , teams all across the country are fighting, when they do this in the community, but for the person gets to the hospital, they can get to 75% or even above. Now, the common hospital diversion. The exact same kind of licensed staff are being contracted, primarily going to emergency departments, but they are being contracted by private psychiatric hospital facilities. They usually call them crisis assessment or crisis triage. It is the same kind of service. It looks a little bit more like hospital rapid response. They do not use the phrase hospital diversion. They use the phrase hospital conversion. And the numerator is the other side of the equation. It is those that are admitted into, not diverted from. And there metric, their target objective is exactly the same number, 75%. Now, the difference between those two is a 50% swing between the potential, when you take the time to engage someone, collaborate with them, there is power in that engagement , but it also gives that mobile team the opportunity to assess all the different kinds of care that might meet that person's needs and what they can do to leverage resiliency , their strengths, the situation , and make that impact. Again, the number is going to vary in what mobile teams are able to achieve. But it is very common. You will see states looking at that target of 75% and you will even see teams that are exceeding that. Wonderful. So, a question for all four presenters. We have had a couple of questions on working with people who are deaf and hard of hearing. A comment around the caller I.D. -based referrals are problematic for people who are deaf as they use relay services. If you are looking at exemplary systems handling interpreting needs for people who are deaf or non-English speaking, what would that look like and anything to add on serving that population? >> This is Debbie Atkins from Georgia. I know that our center actually has the technology and can communicate with our deaf individuals. A George's department has a department within our agency that is for deaf services. They have worked out with our mobile crisis teams to be able to assist as well as our crisis unit. So, we have access to that technology to help individuals who are deaf and hard of hearing. David, we do as well. And we allow the provider to determine the best way to contract for that . It is something that we have in their scopes if they are expected to be able to serve that population. All right. Commissioner Williams , while you are on the line, there is a question about, what are the respite services in Tennessee? What does it look like? You touched on adult and children's, but it is both, correct? It sure is. That is a great question. So, for family members of kids, the respite services entail sometimes having a family respite where there is a contract with a local hotel while that child is somewhere being treated and as it relates to adults, the same thing. Having a contract with a provider that would be willing to provide respite , it is usually up to three days and it is provided. So we really do rely on our local providers to pick out in their community the best resources to provide respite for both kids, families, and adults that are struggling with mental health issues. Thank you, Commissioner Williams. We have had several questions around COVID-19. All four of you mentioned our current national crisis. Has COVID-19 changed expectation of crisis services? Paul, you mentioned a little bit about that. What are the things they have changed to allow it not to change? Are there lessons learned from COVID-19 that you are seeing in your systems that might improve is moving forward? >> Those are fantastic questions, David. I would start by saying it has not changed expectation. We need to accept all referrals and serve those individuals. It has changed how we do it. We have chased down PPE like many others in the community and it has been a lot of work. So, a lessons learned will be that we will have a stockpile of some PPE in the future sitting somewhere in case we need them one year for now or whenever we do. For right now I'm a we have done a few things. Outside of our crisis facilities, one of the things you will see is that we have dedicated first responder drop off areas. We actually have 10 by 10 tents out in front of their so when they show up, we actually have a nurse come through and they are protected with the best PPE we have available for our teams . They are quickly doing an assessment of COVID-19 system symptoms. They are doing that in a couple of minutes. If that individual is demonstrating symptoms, we do our best to get them to a designated area in our facility that are higher risk, therefore isolating them from others and minimizing the risk others might contract something. We do not have testing at this point, although we would love to. What we have is checking for symptoms and we do put them in specific areas of our units as best we can. Some of our units are very small, so we have smaller areas and we have actually had designated , in one place, we actually have an actual designating it for people with COVID-19 type symptoms. Those are some of the things that we have done and we have prioritized our PPE that is available to that specific unit because we need to be prepared to address the needs. The last thing we want to do is have someone in a mental health or substance use crisis be sent to an emergency department where they will certainly be surrounded by people with COVID-19 or put into the justice system where that risk is high as well. We have to keep doing this work and I would say that our team is absolutely chock-full of heroes that are willing to go on and do that work during this very difficult time. Paul, you referenced the potential impact on hospitals early on during the first weeks . We were receiving calls from all of the health plans in Arizona in addition to Arizona Medicaid looking for business continuity plans. We urgently prioritize that the crisis facilities, that they were continuing to be available. We have about 20 to 25,000 times per year that law enforcement is accessing those services and the mobile crisis services . They do not go to the hospital ED at all. If those systems were to be strained or to discontinue in some way, then not only would you have the additional burden of what is happening currently, but you would have yet other demand coming on. We have all worked collaboratively as providers, working together with both Mercy care and access, our Medicaid authority, to make sure that those services work together. The two other pieces, obviously for mobile crisis and for the crisis facilities services, these require face-to-face . It has become more challenging. In those cases, we have worked across , we have a dozen of these facilities across five states, and across all of those we have removed anybody who is 60 years of age or older or has medical complications or an immunocompromised system off of the front lines to protect those most significantly at risk. We have worked collaboratively with both our own sites and other partners and other providers to partner around PPE. Then, everyone who could move to remote and virtual , and obviously crisis call centers, there are out some the was always a virtual call center, but others , Debbie referenced behavioral health links, had to quickly move to being virtual. So we are possible to move people to that situation. That is what has been done. But these key services, again , you know, most of the states we are in are not concerned about breaching the ICU bed capacity and ventilator capacity. There are states where that is a concern. So the importance of these services and allaying unnecessary demand on the hospital -- You know, that is the heart of this presentation and would have been without COVID-19. But it is just a double down concern for the unnecessary lives that could be lost if the hospital systems are not available to serve those in respiratory distress. David, we immediately reached out to Medicaid as we saw this coming. We jointly need agreed that every service that we can allow providers to provide, including crisis services through tele-video, telephone, whatever we could use that would decrease the interaction , face-to-face interaction with people, and still allow us to serve, we moved to do that. I absolutely agree with the statement that we will have stockpile of PPE when this is done and make sure that that is there. This has really been sad , you know, trying to find stuff that you cannot find , you know, frantically trying to find it and you can't find it. Those are the two things that we have done. Great. There is a question for the two states . Well, it went away. It was basically asking for those of you who separate your youth and adult services in mobile crisis, what caused you to do that and, where you talked a little bit about it in your presentation, but what has been the positive results that you have seen , that has basically led you to continue the practice? Right. That is a really great question. This was debated under former Commissioner Jenna back. The debate came down to , hey, we really need providers that understand kids and that is their specialty and continue to contract with providers that understand adult. Part of the debate was that if you do not serve both of them together, then you are really not able to do the family focus. So as we were looking at who the contract with, we did look at, do the providers also provide family -type services . So far, this has been a really good thing in our state. We have not had a lot of complaints. That is sort of the history with that, David. Great. So , I think we have time for one more question. All four of you , how do you think the 988 can best support a conference of, coordinated crisis system? What steps need to be taken to accomplish this in the community and state systems? Marie, do you want to start? Really, just continue to communication and collaboration and focus on how it can enhance and make systems better in showing that it will help you respond to the needs. I think that there is just more community conversation on that that needs to occur. Great. I think for Georgia, having it connected through our GCAL line to help answer that. I think the biggest difference for us will be a relief to the 911 system , allowing law enforcement officers to never be dispatched to use our mobile crisis system and the crisis system we have set up. To have access earlier and more direct so that individuals are not criminalized and have a law enforcement brought in when they really don't need to. >> That, Debbie, was the heart of what I was going to say. I think you hit it dead on. This question comes from one of the people best suited to answer it, Dr. Richard McCann, one of our architects of the crisis system design over the last 20+ years. Without 988, this entire vision of the SAMHSA guidelines could make an impact , but would not be fully optimized because of the natural inclination of folks to call 911. With it, when it becomes operational , and following with these SAMHSA guidelines behind it, it creates something totally different that will have an enormous impact on people's lives, will provide supports without a law enforcement response, which means without an emergency department response. It is going to be not only more effective, but the call cost savings that Paul has referenced again and again are going to be substantial. Thank you all. I would like to thank our amazing for presenters and I would also like to give a special thank you to Dr. McCance-Katz for joining us and a big thank you to SAMHSA for allowing us to share this information with you today. We will now switch to a screen for a short evaluation and ask that you take a few moments to fill it out. If you would like a letter of attendance please reach out to Kelle Masten whose email is at the top of the screen. Thank you all for joining us and enjoy the rest of your afternoon. Please stay safe and well. Thank you, David. Great job. Thank you. Thank you. Thank you. [ Event concluded ] ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download