This report is one section of State Actions to Build the Behavioral Health Crisis Continuum. See the full resource guide.
To ensure effective crisis care, it is crucial to integrate essential principles throughout the crisis service delivery system. These principles, along with the core structural elements outlined in the National Guidelines by SAMHSA, must be intentionally planned and developed within crisis systems. This section showcases examples of state efforts in implementing SAMHSA’s principles, emphasizing the importance of intentional planning and development to establish an effective crisis system.
Addressing Recovery Needs
A recovery-oriented approach to crisis care is a model of care that focuses on supporting individuals experiencing a mental health crisis in their journey of recovery. It emphasizes the person’s strengths, self-determination, and the potential for personal growth and well-being.
State Examples
By adopting a recovery-oriented approach to crisis care, mental health systems can shift from a focus solely on symptom management to one that promotes long-term recovery, resilience, and well-being for individuals experiencing a crisis. Arizona offers guiding principles for recovery-oriented services for adults, while Colorado includes recovery as a part of its behavioral health continuum in its behavioral health strategic plan.
Another important component in addressing recovery needs are organizations operated by and for people with lived experience with mental health issues. Consumer-run recovery centers are a focused space for people with mental health needs to grow in their recovery through self-help, socialization, peer support, opportunities for employment, and specialized wellness programs. New Jersey’s Division of Mental Health and Addiction Services currently funds and supports 33 Self-Help Centers in the 21 counties across the state, all of which are consumer-operated.
Peer Supports
Peer support specialists provide multiple benefits across the continuum of crisis care and in the administration of these services. People engaged in services benefit from peer support services along the full continuum of care through a variety of roles and service models. These models, as well as the roles and responsibilities of peers within them, vary depending on the organization and setting.
In general, organizational structures that deliver peer support services in crisis care include peer-run organizations that may also be referred to as freestanding organizations and are administered by peers. These types of organizations can include drop-in centers and recovery community organizations. Integrated organizations, such as Certified Community Behavioral Health Clinics and other behavioral health centers, offer a range of services, including clinical services and peer-led recovery supports. A third option, hybrid structures, offer a combination of the previous two and are organizations that contract with a peer-run organization for peer support services.
State Examples
Most states have roles for peers in crisis response, often embedded within mobile crisis outreach teams, as a part of inpatient services, and as support for individuals interfacing with law enforcement and the legal system. Peer support workers can also provide individuals assistance in navigating the often-complex system of behavioral health care.
In Georgia, peer support spans all aspects of the state’s crisis system, from the call center staff and certified peer specialists in every mobile crisis team to Behavioral Health Crisis Centers and Crisis Stabilization Units with living room models.
Warmlines provide Georgians the opportunity to receive peer support over the phone 24 hours a day.
The Familiar Faces program in Olympia, Washington, offers another model for how peers can be a part of the crisis continuum. The Familiar Faces program uses peer specialists to help identify and support people with complex health and behavioral problems who have frequent and persistent contact with the Olympia Police Department’s Walking Patrol. The people receiving these services have been noted as having resistance to treatment, so this level of support provides them an opportunity to engage with professionals who have relatable life experiences, including navigating the complex health and legal systems. Washington supports a variety of efforts around peer support, including offering training and resources to organizations that are interested in adding peer support to their array of services.
In Nebraska, the REAL referral program partners with law enforcement, community corrections officers, and local human service providers to offer diversion from higher levels of care by providing a recovery model of community support through highly skilled peer specialists. The program has expanded to offer recovery support to individuals recently released from incarceration in the state’s corrections systems.
Resources on Peers
As states continue to build out mental health crisis systems, considerations for how to leverage limited behavioral health workforce are at the forefront. To address workforce concerns, states are expanding opportunities for peers to support components of mental health crisis services. Leveraging this lived experience, peer services offer states a certified workforce that can provide navigation and other services across a complex system.
Trauma-Informed Care
A trauma-informed approach within the crisis continuum acknowledges the impact of trauma on individuals’ lives and aims to understand their experiences to offer more effective services. By integrating trauma knowledge into policies, procedures, and practices, states can create a supportive environment that avoids re-traumatization of those seeking behavioral health services. This approach has the potential to improve patient engagement, treatment adherence, and health outcomes, while also enhancing the well-being of providers and staff.
State Examples
In Oregon, extensive collaboration on trauma-informed care across child, family, and adult systems led to the establishment of Trauma Informed Oregon. This state-initiated program serves as a central hub for information and resources, facilitating coordination and providing training for health care and related systems. By partnering with state agencies, local providers, communities, family and youth organizations, and diverse partners, Trauma Informed Oregon fosters a collective approach that embraces various voices and perspectives.
A multi-pronged strategy by the Missouri Department of Mental Health revolves around actively promoting trauma-informed approaches through an array of approaches. The Missouri Department of Mental Health supports trauma-informed care in a variety of formats, including free and curated resources on trauma-informed care, a focused and long-term trauma initiative, and trainings aimed at professionals, people receiving services, and youth.
Zero Suicide/Suicide Safer Care
Zero Suicide is an approach and philosophy aimed at preventing suicide by creating a system-wide commitment to comprehensive care and support. It emphasizes the belief that suicide deaths are preventable and sets a goal of reducing the number of suicides to zero. The Zero Suicide approach involves implementing evidence-based practices and interventions across various settings, including health care systems, mental health organizations, and community support networks. It emphasizes the importance of early detection, risk assessment, and intervention, ensuring that individuals at risk of suicide receive necessary care, treatment, and support. Zero Suicide promotes collaboration among health care professionals, educators, policymakers, and the wider community to address the complex factors contributing to suicide and provide a comprehensive, compassionate, and effective response to those in crisis.
State Examples
Colorado’s Zero Suicide approach combines targeted funding for framework implementation in pilot health systems, telephonic follow-up services for people transitioning out of hospital treatment, clinical training, and collaborative learning and community-building efforts led by the state. With funding from the Legislature and the U.S. Substance Abuse and Mental Health Services Administration, the Colorado Office of Suicide Prevention began work on a statewide Zero Suicide strategy in 2017.
Utah’s Live On is a public-private mental health and suicide prevention campaign focused on changing social norms to reduce suffering and save lives. The population-oriented, evidence-informed effort brings together diverse partners to encourage mental health and suicide prevention as a statewide priority; to promote awareness and acceptance around help-seeking, safe firearm storage, and stigma reduction; and to highlight people with lived experience in loss and recovery. Under HB 393 (2019), the Utah Legislature matched funds from private donors for this effort.
Safety/Security for Staff and People in Crisis
The safety of both individuals and staff is crucial in all crisis service settings, as these settings are responsible for assessing and managing potentially life-threatening situations such as suicidality and aggressive or violent behavior. States are actively implementing measures to prioritize the safety and security of both staff and people in behavioral health crises across crisis service settings. This commitment is evident through various strategies, such as the advancement of evidence-based practices, comprehensive training, robust reporting systems, standardized protocols, and patient-centered models throughout the crisis continuum.
State Examples
To ensure the safety of individuals during transportation, Oklahoma enacted legislation in 2023 that restricts the use of mechanical restraints. In Massachusetts, comprehensive mental health legislation includes the implementation of online portals and protocols facilitating a more efficient search for mental health beds in hospitals, reducing emergency room boarding crises. Additionally, Arizona is taking steps to establish a regulatory framework for patient safety by requiring all health care employers to develop and implement written workplace violence prevention plans, including training requirements and reporting systems.
Crisis Response Partnerships with Law Enforcement
States are actively modernizing crisis response systems by strengthening community relationships with law enforcement agencies that frequently interact with individuals facing mental health or substance use disorder crises. These community-based partnerships play a vital role in ensuring public safety, preventing suicides, connecting people to appropriate care, diverting people from the justice system, and ending psychiatric boarding in overcrowded emergency departments.
State efforts primarily focus on legislation that promotes deflection programs, linking individuals to behavioral health treatment, recovery, housing, case management, or other essential services. States support community-based partnerships with law enforcement by encouraging local collaboration, providing standardized definitions and authorizations for models, and offering funding to enhance these partnerships effectively. Two examples of local community initiatives are:
- In Dallas, community leaders and partners have successfully implemented RIGHT Care (the Rapid Integrated Group Healthcare Team), a community paramedicine-based program that combines a paramedic, a licensed master’s level mental health professional with extensive experience in mental health emergency care, and an experienced law enforcement officer with advanced crisis and mental health peace officer training to provide integrated, health-driven responses to medical emergencies for individuals with chronic illnesses.
- The SMART program in Los Angeles exemplifies the embedded co-response model and highlights the distinction from the specialized response model. Operated jointly by the city’s police department and Department of Mental Health, SMART teams consist of law enforcement officers and mental health professionals who receive extensive training. Unlike the specialized response model, SMART does not use the 40-hour crisis intervention team training curriculum, but rather relies on the expertise of the embedded mental health professional to address crisis situations, reallocating resources to bring specialized mental health skills to the team.
Dispatch and Emergency Medical Services
With the 988 transition, state behavioral health leaders are establishing relationships with 911 and its related public safety answering points (PSAPs) to ensure coordination of crisis care for those who need it and continue to foster responses that default to police when there is a critical need to do so. State efforts focus on a range of activities, including:
- Enhancing interoperability and building out information systems
- Building essential communication links required within and between public safety and 988 behavioral health crisis communication systems
- Creating new partnerships with 911 and other partners to coordinate across systems
- Facilitating data-sharing between emergency medical services teams and mobile crisis teams.
An example from “Crisis to Care: Building from 988 and Beyond for Better Mental Health Outcomes,” highlights behavioral health authorities in Washington State actively engaging with 911 services, familiarizing themselves with computer aided dispatch, automatic call distribution systems, and the functions of PSAPs. The objective behind these efforts is to create well-coordinated networks that can rapidly respond to 911 and 988 calls pertaining to behavioral health crises.
In Denver, the Support Team Assisted Response (STAR) Program deploys emergency response teams that include emergency medical technicians and behavioral health clinicians to engage individuals experiencing distress related to mental health issues, poverty, homelessness, and substance use. STAR responds to low-risk calls in which individuals are not in imminent risk. STAR is dispatched through Denver 911 Communications. The team can provide medical assessment/triage, crisis intervention, de-escalation, transportation, and resource connection for community members in need.
The CAHOOTS program in Eugene, Oregon, is made up of teams of medics (nurses or EMTs) and mental health professionals who can be dispatched to the scene of crisis calls by 911. CAHOOTS is operated out of a community-based organization that partners with the 911 system to respond to crisis calls that do not require the presence of a police or ambulance. In this way, the mobile response program coordinates with the law enforcement system but is dispatched independently to the scene. Notably, the Medicaid mobile crisis incentive is modeled on the CAHOOTS program.
Workforce
States across the nation are facing mounting challenges in preparing and developing their workforce to meet the growing demand for behavioral health services throughout the crisis continuum. Recognizing the unique factors and solutions required to address workforce needs within the crisis continuum, states are proactively taking a variety of approaches to bolster their capabilities in this critical area, including:
- Expanding the scope of crisis service providers: Some states are investing in training and credentialing non-licensed individuals to broaden the pool of workers who can provide crisis services (e.g., 988 crisis lines, mobile crisis teams, and peer respite centers).
- Enhancing skills of current workforce: To improve crisis response and care, states are focusing on upskilling existing behavioral health workers in specific components of the crisis continuum. This targeted training ensures that the workforce is equipped to handle complexities and challenges that arise during crisis situations.
- Emphasizing flexibilities: States are adopting flexible approaches to address behavioral health workforce shortages. By exploring innovative options, they can effectively deploy resources and personnel where they are most needed.
In Utah, the state has introduced the Crisis Worker Certification and a certified crisis worker career path. This initiative aims to expand and strengthen the current and future crisis workforce, ensuring that more professionals are well-prepared to provide essential services during times of crisis.
To address behavioral health needs in rural and frontier areas, Alaska has developed a training program for behavioral health aides (BHA). Certified BHAs, often members of the community who possess cultural and historical understanding of their clients, offer Medicaid-reimbursed services within an integrated care model. (To learn more, read the NASHP blog post “How Alaska Supports Rural and Frontier Behavioral Health Services.”)
New Mexico is expanding peer support in its crisis continuum efforts. The New Mexico Crisis Access Line works alongside a peer-to-peer warmline, where trained staff triage calls and offer individuals the option to be connected to either a peer or a clinician, based on their preferences and needs.
Some states, including North Carolina, are updating their Medicaid plans to allow Medicaid reimbursement for additional qualified professionals based on training, service type, and settings for their crisis services. Crisis services may now be provided by a variety of combinations of workers, and those services can be provided either by two team members in person or by one team member in person who works in partnership with another available via telehealth.
Rural and Frontier Crisis Challenges
States are presented with an acute set of challenges when addressing the provision of behavioral health crisis services in rural areas. Along with higher behavioral health workforce shortages and fewer behavioral health resources in rural areas, the rate of behavioral health crises, including drug overdoses and suicides, are dramatically higher in rural areas than in urban areas. A NASHP policy academy on rural crisis challenges, which focused on work in Montana, South Carolina, South Dakota, Texas, and Wisconsin, released a rural crisis policy brief on emerging state strategies for bolstering the rural behavioral health crisis care continuum. Some of these strategies include expanded access to crisis call centers, mobile crisis teams, crisis stabilization units, and post-crisis support.
CCBHCs: Strengthening the Behavioral Health Crisis Continuum
Designated Certified Community Behavioral Health Centers (CCBHCs) clinics play an important role in the behavioral health crisis continuum due to requirements of comprehensive and person-centered services during acute crises. Funding is tailored to individual state Medicaid programs and federal opportunities. The prospective payment model allows providers to include clearly defined crisis services within the fixed per-member per-month (PMPM) payment to ensure adequate coverage. In 2023, 15 states received SAMHSA planning grants, and up to 10 will participate in the CCBHC Medicaid demonstration program with enhanced reimbursement in 2024.
