Resident Eagle: St. Louis' Mental Health Alternative

Resident Eagle is a monthly column profiling the work of top EMS physicians and medical directors from the Metropolitan EMS Medical Directors Global Alliance (the "Eagles"), who represent America’s largest and key international cities. For information on the Gathering of Eagles 2022, see useagles.org.

Discussions several years ago among public safety officials regarding bail bond reform measures led to the city of St. Louis creating a unique system to divert certain 9-1-1 calls away from a traditional police/fire/EMS response. With some low-threat mental health-type calls, the dispatcher now assesses the situation and sends the calls to Behavioral Health Response, or BHR (bhrstl.org), an agency that provides crisis support, telephone counseling, and mental health resources via trained clinicians 24 hours a day, seven days a week. 

When calls are diverted to BHR, mental health professionals will provide a plan for the moment and then work with the caller for long-term treatment services. If the therapist feels the caller needs immediate in-person assistance, 9-1-1 is reactivated, and a clinician and police officer are sent to try to deescalate the situation. 

St. Louis Fire Department medical director W. Scott Gilmore, MD, EMT-P, FACEP, FAEMS, has been part of the planning process from the beginning.

“This all started as we looked at how mental health affects the justice system,” Gilmore says. “Because of this theme constantly recurring, we started to look at what other cities and towns were doing.”

The group included Gilmore; St. Louis Director of Children, Youth, and Families Wilford Pinkney; representatives from the St. Louis Metropolitan Police Department; and public defenders, prosecuting attorneys, and representatives from the courts.

“We saw what some other cities and towns were doing with behavioral health emergencies, and because of this exploration, we decided we needed to do something in St. Louis,” Gilmore says. “The idea is to send mental health liaisons out to the scene, and if it is secured, they can talk to the victims and witnesses. In addition to helping the person in a mental crisis, we also want to make sure victims and witnesses to crimes don't go down the same path.”

Gilmore says a unique piece to the St. Louis program is that BHR, the agency fielding the mental health crisis calls, is separate from the 9-1-1 dispatch center. 

“The other programs are actually in the 9-1-1 dispatch center,” Gilmore says. “We are the first program in the country to have the agency completely separate.”

Program Components

The first prong of the program is the 9-1-1 diversion element. Gilmore, Pinkney, and Bart Andrews, PhD, chief clinical officer for BHR, collaborated to design the criteria for the types of calls to be diverted. 

“When a person calls 9-1-1, they are assessed quickly by means of 2–3 questions, such as if they are in the process of attempting to kill themselves or whether the person having a behavioral health crisis is violent,” Gilmore says. “If violence is threatened, the crisis response unit (CRU) or a CIT (crisis invention team) police officer and ambulance are dispatched. If the answer is no, the patient is asked if they would like to speak with a behavioral health specialist. If the person says yes, they are transferred to BHR.”

BHR then handles the call in lieu of dispatching EMS or the police. This part of the program launched in February 2021.

“At BHR a trained clinician interviews the caller further to see if they are already in the system and just need help getting [reintegrated] or if they are new to the system. Around 35%–50% of callers already have access to services and can be reconnected to those providers,” Gilmore says. “During this interview, if there is a medical emergency discovered or if the caller needs to be transported to a hospital for acute stabilization, 9-1-1 is recontacted, and the police and/or EMS respond. During this response BHR stays on the line with the caller the entire time to help defuse the situation.”

A second component is the “cops and clinicians” program that has now become the CRU. This is a joint effort of BHR and the city that began in May 2019 as a pilot program in one part of St. Louis. 

“In this portion of the program, a community mental health liaison (CMHL) rides along with a CIT-trained officer responding to behavioral health calls or following up with established contacts,” Gilmore says. “This program has been very successful because both resources are on-site.”

Third, the group found there is a link between mental health and substance use. Thus there are plans to open a sobering center this year. This will be colocated with a federally qualified healthcare center. Police and EMS will be able to transport directly to the sobering center, where the patient will be screened not only for substance abuse but also for other needs involving mental health.

“This is a multiprogram approach,” Gilmore says. “The goal is to be holistic and inclusive.”

The program's elements are expensive to start up and maintain. St. Louis initially earmarked $860,000 from its general revenue funds to help pay, and funding also has come from the Missouri Department of Health and Senior Services. BHR, which is a nonprofit, is working on securing more sustainable funding for the long term.

Appropriate Responses

When the program started in early 2021, officials predicted approximately 5,000 of the 700,000 annual calls to the city of St. Louis’ 9-1-1 system would be diverted. Gilmore says the most common time for such calls is between 2:30 p.m. and 10:30 p.m.

“Most of the people in such a crisis usually already have some kind of disability or long-term mental health or substance abuse issue,” Gilmore says. “They stay up all night and then sleep in. Then things start over again in the afternoon into the evening.”

Through June 2021 there have been 312 such unique calls to 9-1-1, with more than 58% diverted from police or EMS involvement. For June, for example, 16 of 28 calls were linked to behavioral health services, and 21 of those 28 were diverted from emergency psychiatric services.

For the crisis response unit in the week of June 20–26, there were 141 contacts: 120 were diverted from the subject being taken to the hospital (27 were resolved on scene, 48 were referred to community behavioral health, four were referred for next-day urgent screening, six were referred to their existing provider for follow-up, and one was referred for emergency substance use treatment). 

None of the callers were arrested or detained.

“The goal is to not have to send them to jail or the hospital psych ward because it might actually cause bigger issues long-term,” Gilmore says. 

Susan E. Sagarra is a writer, editor and author based in St. Louis, Mo.