Monday, March 31, 2008

Crisis Teams: When does a crisis involve boots on the ground?

Families are frustrated by long waits in the Psychiatric Emergency Rooms that are happening all over the Commonwealth, and the remedy proposed that we move those services out to the home.  One would hope that, in the context of Intense Care Coordination and consistent screening programs, we would have fewer families in crisis requiring that level of intervention. Crisis intervention is a terrible way to manage mental illness.  Of course, it will be difficult to maintain a level of expertise in this area as it becomes less common.

(1) What suggestions do you have for structuring the Mobile Crisis Intervention service across the Commonwealth?
The first thing to realize is that a 45 minute response time is not possible in many parts of the Commonwealth unless Masshealth is going to pay for helicopters. In South Worcester County, it takes that long to get to Brimfield or Ware. The standards for “Crisis intervention” need to be rewritten to reflect that reality. Most crises happen in the context of poorly coordinated care for children previously identified as having difficulty. That said, crisis management requires three things:
1) “De-escalation”: Like Henry Goldblum on the old “Hill St. Blues” TV show, we need people among the “first responders” (police, EMT and fire fighters) who are able to “talk down” the person involved in the “immediately” dangerous behavior. That person should be local, and able to contact the Mobile Crisis Team for the region in which they work.
2) Transporation protocols: Universal protocols for transport to Emergency Mental Health Services, covering issues such as the use of physical and chemical restraint, ambulances vs. police vehicles and notification of family.
3) Mobile Crisis Protocols: These should include discretionary powers on behalf of the Team to decide the level of intervention needed at this time.
4) Emergency Planning: Calling the team or designation as a member of the SED class should involve the development of an individualized emergency plan for the child and family.

(2) What is the appropriate number and qualifications of staff for a Mobile Crisis Intervention team? 
They probably need to be similar to the requirement for Emergency Mental Health work in general.
(3)What suggestions do you have regarding coordination of Mobile Crisis Intervention with other services, including the other Initiative Services discussed in this RFI?
From Chris Stille:  
As discussed in the response to 2.1.3, 2.3.B(1) and 2.3.B(4), there is a need for crisis plans and crisis teams to engage in communication and coordination with the child's ongoing medical (including primary care) and mental health service providers, as well as with their school. The goal of this process would be to help children and families transition smoothly between levels of care (both up and down the urgency/intensiveness ladder). We feel this would be facilitated by proactive designation of a person or small group of people as each child's crisis team, ideally determined BEFORE a crisis occurs. This would further enable well-planned, well-coordinated care. 

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