The Future of EMS Response and Behavioral Health

The face of emergency response for behavioral health patients in the US is on a trajectory of change. For decades the response to behavioral health emergencies across America has been uneven at best. The deaths of Elijah McClain, Miles Hall, Herman Whitfield III, and too many others in communities across the United States have spurred law enforcement agencies to transition out of providing behavioral health response.

SAMHSA’s National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit (https://bit.ly/SAMSHAGuideBehavioralHealthResponse), identified the essential components of a system of care. They are a 9-8-8 call center to provide telehealth, assist, direct, and when necessary dispatch care teams for behavioral health requests; mobile crisis response teams who proceed directly to the scene to provide care; and crisis receiving centers where patients may be transported to if interventions via 9-8-8 or by the mobile crisis response team if a patient requires a greater level of care.

Communities are implementing these changes in a variety of ways. This will have a tremendous impact on EMS agencies across the country. While the framework of a system of care has been described, just as in EMS, the service delivery model for every community will be different. EMS agencies may be called upon to develop their team or work in conjunction with a team from another city department. There will be challenges with the 9-1-1 and 9-8-8 interface, operational concerns about who needs to respond, engagement on the scene with other providers, and who will transport patients when they need care at a behavioral health facility.

In response to all of the activity that has been taking place across the country, on June 1st and 2nd in Washington, DC, the New York University School of Law Policing Project (https://bit.ly/PolicingProjectNYUSchoolofLaw) and the Georgetown School of Law Center for Innovations in Community Safety (https://bit.ly/CICSGeorgetownLaw ) held a convener for programs who are providing alternative response in communities across the US. The Future of Alternative First Response: Building Sustainable and Scalable Programs (https://bit.ly/Alt1stResponsePrograms) was a multi-disciplinary program. Representatives from police departments, EMS agencies, 9-1-1 and 9-8-8 call centers, academics, elected and career government officials, the social work community, attorneys, and mobile crisis program directors, all came together to discuss the origins of their programs, celebrate their success, to share each other’s challenges, and to exchange ideas.

The diversity of programs in attendance was incredible. A small sample of the public agencies taking part included Albuquerque Community Safety, Chicago Fire Department, Oakland Fire Departments MACRO team, Denver 9-1-1 and Public Safety, City of San Francisco, City of Tucson, Williamson County Texas 9-1-1, all who were either participating on panels or were in attendance participating in workshops, and sharing ideas.  There was a comparable array of non-profits, from across the country as well, the Dayton Mediation Center/ Mediation Response Unit, the Atlanta Policing Alternatives & Diversion Initiative, and CAHOOTS in Oregon, to name a few.

Lessons shared

I attended this program as the President of the International Association of EMS Chiefs, but I also have a mobile care response team that is provided as part of the department I work for. Here are the key takeaways for every EMS organization.

The provision of this level of care is coming to every community in the US. If you were tasked by your city government to provide this service, who will you utilize in this role? The response team staffing may include EMTs and paramedics whether it is provided by your EMS agency, your local law enforcement agency, or by a non-profit contracted to provide service in your community; or your EMS agency will probably respond to a patient who needs assistance while in the care of one of these teams. The interaction on the scene will be crucial to the patient's outcome regardless of the city department or non-profit agency.

Developing clinical pathways, working through hot and warm hand-offs, and building the capabilities to work collaboratively when both sets of clinicians are on the scene are critical to that success. While we currently call this an alternative response model we should begin to recognize these professionals as equals in the first responder realm.

What types of training will our staff require? How will you orient your staff to the mobile crisis team and how will you orient the mobile crisis team to your EMS agency? What additional training will these behavioral health providers need if they are not EMTs or paramedics? First aid? CPR?

The common thread was concentrating on sending the right resource for the right type of request. Everyone wanted to supplement their current police agency with an alternative response model. This would free up police officers to respond to other incidents where their expertise would best be put to use. It would ensure better outcomes for people in crisis and by employing de-escalation techniques a trained team could reduce the circumstances that would require having someone involuntarily committed, or having a need to be placed into restraints, or worse where an incident would escalate into a violent encounter.

Everyone acknowledged that a 40-hour training program, whether it was for police, EMS, or other behavioral health professionals, was not sufficient, we needed to do a better job educating our responders. In the example of EMS or even a police response, if they were not going to be the primary responders for behavioral health calls, they would still encounter patients with behavioral health problems whose homes had gotten broken into or who were suffering a heart attack. That interaction could be a success or a disaster.

Many programs that initially had law enforcement as part of their configuration, developed a reduced police presence over time. Law enforcement agencies identified other categories of calls for these new teams to respond to. In one instance teams were responding to 2 or 3 categories of calls in one community, but when their law enforcement partners saw their effectiveness firsthand this expanded to 17 categories of responses, requests that were previously handled by that police department for decades.

The staffing options ran the gamut from some combination of a police officer, an EMT or paramedic, a social worker, peer support specialists, licensed clinical social workers, and behavioral health technicians. As many agencies there were in the room there was an equal number of configurations. There were a multitude of factors that accounted for this, one being the capabilities and capacities of the communities who were developing programs. The second was shortages of different types of providers. One program reported that they had a hard time attracting licensed clinical social workers, even with incentives and bonuses. In another example in one city, they hired only basic EMTs for their service because there was a shortage of paramedics and they did not want to exacerbate that problem.

Regardless of the co-responder model chosen, it was amazing to see that all of the programs reported success. This is important because it doesn’t lock anyone into a specific model to meet the needs of their patient population. An EMS service could hire peer support specialists if they had problems attracting LCSWs or if there was a shortage of paramedics in their community for example.

Training is fundamental to the program. Academics, city officials, first response organizations, and behavioral health program directors alike were in agreement: short-form, forty-hour educational programs did not prepare providers for the dynamics of community response. For example, the peer support specialist training in one community totaled 260 hours. That was more than twice as long as my first EMT class.

The framework of the system for behavioral health emergencies has been described by SAMSHA, but the service delivery model will be unique in every community. Who will provide 9-8-8? Will it be part of the 9-1-1 center or some other entity? Will the city hire their behavioral health clinicians or will they contract out with a non-governmental entity?

Where will this new group reside or will it stand alone? In discussions with the different teams present, if an EMS agency was providing crisis response, they provided it as part of their community paramedic program, where they may be performing outreach to the unhoused and working with patients who had substance use diagnoses. If the program was contained within the police department they not only responded to behavioral health requests they might also be tasked with performing conflict mediation between neighbors and other types of calls that typically went to the police department via 9-1-1 but did not require a law enforcement response. If an agency was not based in either agency it straddled a line between the two, working with those who had a wide variety of needs, that for decades had been referred to 9-1-1, but did not require a police or EMS response.

Another presentation discussed benchmarks, outcomes, and success. How do you define success for your program, your community, and most importantly your patients? What are the methods employed, the benchmarks you developed, what are the outcomes that you are trying to accomplish, and the impact you have achieved? It was essential to bring in researchers early on, to define and later on refine not only your benchmarks and identify outcomes, but to measure the intended and unintended impacts of the program.

The future of alternative response models for behavioral health emergencies holds immense promise in revolutionizing how EMS approaches and addresses these critical situations. By shifting the responsibility from the traditional response models, we have employed specialized teams, equipped with the necessary training and expertise in behavioral health, we can provide a more compassionate and effective response. This new service delivery model aims to prioritize de-escalation, empathy, and access to appropriate resources, fostering an environment where individuals in crisis can feel supported and understood. As we continue to evolve and refine these alternative response models, we have the opportunity to create a more holistic and person-centered approach to behavioral health emergencies. With the right investment in training, resources, and community collaboration, we can pave the way for a brighter future, where those in need receive the care and support they deserve, ultimately fostering healthier and more resilient communities.