Alternative Response to Behavioral Health Emergencies: Beyond Police (December 2023)

I'm director of the Christian reaghard Center for emergency response studies here at John J College of Criminal Justice and uh for those of you who are new to the uh our event series we hold a monthly series of lectures uh or events during the academic here um on various topics related to uh emergency response kind of broadly defined uh the center is actually named for probationary firefighter Christian rehard who died in the collapse of the N 911 in the collapse of the World Trade Center and so uh I will send out a link to our web page for those of you who may not have it um just some housekeeping uh this conf this conversation will be recorded and we'll send a link uh to the edited video uh once it's completed usually within a week or so and uh uh normally we will take all the questions in through the chat feature um and just a reminder please remain muted um with your video off through the uh discussion uh all right so with that um I want to uh introduce today's talk and it's really a timely topic uh we're pleased to have Dan Gerard or Daniel Gerard who's currently president of the International Association and VMS Chiefs um and uh Daniel is working with the center uh on a project that we're completing for the international City County management association the icma looking at emergency response um to behavioral health uh incidents uh kind of nationally and and trying to decide discern lessons and uh kind of strategic areas of focus uh and the issue of course is a big one one that been getting a lot of attention and continues to and there is still no real consensus nor necessarily should there be a consensus on a single ideal model uh but there different communities are taking different approaches and uh there's a lot of work being done in this area so we're very pleased to have uh Daniel with us today and so with that I will turn it over to uh Dan let take it away uh thank you Dr Jennings it's a it's a pleasure to be here with everyone today uh let me share my screen here and let me see if this comes up um can everybody see this looks like you got it actually we've got your uh that is that is that better yep yeah we're good so today I'm gonna talk about uh developing a community-based response model for patients in crisis and a large part of this comes from the work that we did on the icma project but also uh from my experience uh operating a community uh mental health Response Unit uh where I'm at in California um I don't know why it's jumping around like this uh I have no financial interest in mobile crisis response and as I stated my uh Department currently operates a uh mobile crisis team uh I'm not a licensed clinical social worker but I did get to meet Randolph Mantooth and uh I guess you have to be a particular age to appreciate that but if you Google Squad 51 an emergency you will understand the significance of that statement this is a short article on developing a mobile crisis response team uh I'm the author of it I published it last year I believe uh through EMS world but if you if you're taking notes if you're uh looking to gather additional information uh you know this might be something that you could share with other people and it you know hopefully it will have some uh good information for you in there I need to provide a warning to you I have one or two video clips in here that show encounters with patients that are in crisis that unfortunately resulted in their death and uh it again it is a violent death and so I'm giving you this warning now and I will also give you a heads up warning again before we play the uh video so um if you know if this isn't uh if this is of a concern for you um you may uh either avert your eyes or turn turn the volume off on your computer or you may uh you know you may log off um at that point so as Dr Jennings pointed out um I'm an EMS coordinator for fire department in Northern California uh I'm the president of the International Association of uh EMS Chiefs I'm a former professor in the EMS degree program at George Washington University and currently I'm a doctoral student in organizational leadership and health policy uh but in case you didn't guess I'm not originally from California uh I'm a jersey guy born and raised I spent uh 20 years as an EMT and paramedic in Nork New Jersey I cut my teeth on the volunteer first aid Squad and I had the opportunity to uh work around the world I did the EMS system redesign in Hong Kong I worked for Chrome monel at the time I did a little bit of work with the Pan-American Health Organization and I got to author a co-author a book uh with them uh emergency Medical Services uh Lessons Learned From the United States of America and I worked in the Bahamas which was uh extremely difficult and I've uh uh because you know we we uh we went to lunch every day at 12 and essentially didn't go back to work and I've worked with various members of the federal government um on both sides of the aisle a lot of people ask me why I left New Jersey to go to California this is not the reason why um and I want to kind of plant this seed in everybody's head I think a lot of times we talk about alternative response and we use the term alternative response but realistically I think that we should be talking about appropriate response and I think that when we use the term alternative for some people it's almost as if it's lesser than and really if we start thinking about appropriate response then we think about it as an equal in our space so before you know we used to think a 911 as police fire and EMS now we need to think about it you know police Fire EMS Behavioral Health response and they also have their own number they have 988 too but we'll talk about that in a little bit why the big push for us to speak and and work with patients with mental health disorders the ball was kind of put into play over 30 years ago and was recognized by the World Health Organization that we were going to see a tremendous Ro eyes and mental health disorders across the globe and when we look at the numbers it really becomes overwhelming when we think about it before we sort of captured health and mental health and we thought about them as two different entities and really mental health is health and we need to approach it from that standpoint our biggest challenges are not only the people that we encounter every day who have mental health disorders but also people that we have a tendency to warehouse and when I talk about Warehouse I'm talking about uh individuals that are incarcerated where the access to services and Care isn't equal to what they have on the outside and then individuals that are I want to say undomiciled don't have the same access to care and so as crazy as this sort of sounds we sort of Warehouse undomiciled people on the outside of the Health Care system and they don't have the same level of access and then we don't get the opportunity to interact with them until they're absolutely in crisis but this issue and this problem has accelerated because of covid Co when we started bringing people inside and we started isolating them from other individuals it created an incubator effect that in essence made the signs and symptoms of mental health conditions and problems more prominent it made them more visible it accelerated the problems that we were viewing in the community and in society as a whole so the first thing I would ask you is how many people in your community require behavioral health or crisis services and you know we've never had a really good number or a really good handle on that in major cities when we talk about cities like New York or Houston or Los Angeles we sort of we have a better idea than we do in smaller communities but realistically a lot of this has to do with response models and how we report information back and how we gather information how do we plan to respond to these types of events you know sometimes it's after a very tragic event unfolds so somebody dies as a result of a poor response and now we have to re-envision ourselves what we're going to do how we're going to respond in the future and this is really sad when you think about it because you know someone had to die or suffer needlessly in order for a change to happen and in some places it's part of an ongoing process of evaluation so so when we look at places like Chicago Atlanta uh Los Angeles San Francisco you know uh New York City to a degree um you know this is part of an ongoing process of evaluating what they do in the community re-evaluating it coming up with new plans coming up with new approaches and working on it I would say that places like Los Angeles and San Francisco um have been working the system and trying to develop a system for a longer period of time but I also don't want to leave out our friends from Chicago and Atlanta as well because they've been doing some tremendous work as well here let me so how do you currently provide service you know one of the things we found out is that sometimes this is based in a single agency it may reside within the police department as a matter of fact and I'll get into this in a little bit more detail and a lot of organizations and a lot of places um you know this was U you know this was primarily a police response for time in Memorial uh some organizations uh some cities provide it as contracted service and they will partner uh generally with a nonprofit or maybe a Health Care system system and they will have a mobile team that will go out and work with individuals uh in some organizations it's part of an interdisciplinary team so uh and they call this a co-responder model so you might have EMS police and some type of Social Work team responding to this and unfortunately in some locals it's whoever is available so if we have a police card respond we're going to send a police car uh if the police aren't available we'll send EMS uh but you know we'll get somebody out there it's in the Q and we're going to respond to this as soon as we can so why mental health mental health I'm sorry I don't know why I did that um mental health has significant impacts not only only on the psyche of the individual but also on their physical health overall crisis response in many locals for decades was primarily a law enforcement responsibility and the police assumed that mantle for a variety of different reasons if you go back in history and we look at this we will see places like Chicago New York um La where they have looked at uh we're Prim they had a social worker before that would go out into the community and work with members of the community and over a period of time you know that kind of got to be too expensive and so instead of sending a team of social workers out into every Community they would have the social workers based at a hospital or some other uh government facility and then they kind of transitioned it over to the police because the police wore the boots on the ground they were patrolling every day and I'm talking about in a in a lot of locals you know cop I'm I don't mean to use cops but uh law enforcement you know were primarily on footbeats and everybody in the neighborhood knew the local police officer and they kind of had their pulse on the community over a period of time and to a certain extent this probably made sense but we really needed the psychiatric social worker we needed the social worker as part of that and then over a period of time there was this change in the social and political construct and negative interactions between police and the people that they were trying to assist many of these have come to the for over a period of time because of body cam footage because of cell phone footage and it has given us a a greater opportunity to see what we're doing why it isn't working and what we need to do better and this is be this has gained increased emphasis over the last uh 10 years because as the rise of mental health disorders has occurred and as it's become more prominent coupled with the fact that we have more uh a video documentary of what is happening in the community it has made many of us turn around and say there has to be a better way so many uh communities across the United States look to transition from a police response to an appropriate response model some places are still going to call it alternative response and you know I'm I uh I feel like Don keyote here I'm tilted at windmills when I say this but uh you know they've transitioned from police response to uh an uh an appropriate response model or a co-responder model and places like uh Cahoots in uh Oregon I don't want to say that they were one of the first but I think they were one of the first to gain national attention with their change in from a police model to one where they have peer supports Specialists and paramedics and EMTs to go out and work with individuals uh there's a lot of energy right now uh for organizations to go with the co-responder model where they have some type of EMS presence where it's an em or paramedic uh they have a police officer and they have a licensed clinical social worker or maybe Behavioral Health technician or peer support specialist and they respond out as a team uh the police officer dresses down you know he's probably wearing khakis and a golf shirt um if he's carrying a weapon it is not visible uh and in some places have uh contracted wholly out to outside agencies uh these uh non-governmental organizations that work in the behavioral health space and they have no law enforcement response whatsoever so when we have this corresponder model and we have these uh outside contracted Services generally what we're seeing is that we're only sending them uh to these nonviolent patients or these nonviolent responses and at the same time we're also providing them with a deescalation training which is essential and I'll I'm going to talk at length about the uh training component in a little bit but uh you know we're trying to you know realizing that uh these are people that are in soft clothes um you know we want them to be actively engaged in the community at the same time you know we don't want to put them In Harm's Way now sometimes when they're dealing with people that are in crisis you know they need that deescalation training to lower the temperature and BR try to bring the PE the client that they're dealing with more in line in order to be able to assist them and so for these corresponder models we see a variety of different um struct structures to them and so uh you know I'm a paramedic and a registered nurse uh and so you you might see you know you might see a registered nurse that's part of the team and some organizations have that some organizations have some uh form of EMS provider whether it's an em or paramedic a law enforcement officer and a licensed clinical social worker or a peer support specialist and a licensed clinical social worker Behavioral Health technician and a licensed clinical social worker uh some organizations there are some EMS models where they have an EMT and a paramedic and they leverage a tella health model in order to contact their uh licensed clinical Health uh licensed clinical social worker or their behavioral health specialist and you know they'll you know they'll get them they'll get the you know they're using something Ain to First net that's a hypoc compliant they'll get their uh they'll get their provider on the phone and you know they'll hold the phone up and you know they'll they'll interact with the patient that way or they may just do a a phone consult where they either discuss the case with the behavioral health specialist or they pop the patient on the phone but there are as many different cities as there are in the United States there's probably as many different well that's getting a little crazy but as many different communities there's as many different Service delivery models a lot of this has to do with capabilities and capacities within the communities that we're talking about and for me I'm in a primarily urban area and so you would think that it was easy for me to access behavioral health personnel to to roster out on on our uh crisis mobile team but actually we use a tella Health option because our call volume isn't at the point where we could support someone fulltime um in rural areas in the United States and Frontier areas in the United States tella Health may be the only option again because of the pity of calls the distance between patients and inter actions and again it just may not be able to support that licensed clinical social worker but you have a variety of different um uh configurations that can take place and it doesn't um you know the tella Health option or any other option isn't necessarily a geographical issue you know it just might be a Personnel issue one of the things that I want to point out is that for the mobile crisis response one of the things that we learned right away was time on task so you know I cut my teeth in this business in EMS and you know over a period of time you know you kind of figure out Hey listen you know we're going to this patient's house they have asthma we've been there before this is like a 20 minute call you know we're going to be on scene 20 minutes we're going to get a set of Vital Signs we're going to give the patient albuterol treatment maybe we're going to start an IV and give them some cedral pop them in the chair bring them down the stairs reassess them give them another nebuli treatment and away we go uh and it's the same thing with chest pain patients when we moved into the mobile crisis realm the EMTs and paramedics realize right away that the shortest amount of time that they were going to spend on scene with somebody who probably about 45 minutes to an hour you know average time on task with some of these patients is about two hours we've gone six or seven hours on scene with one patient the other issue you know that you have to sort of figure out is transport if you have a client that you encounter and you need to bring them into a behavioral health facility or you know that you need to bring them in uh you know to see a a counselor on an outpatient basis how are you going to get the patient there uh you know I mean we could call the 911 ambulance but really realistically we only call the 911 ambulance if the patient has to be restrained because with restraints there's a greater chance that there's going to be a negative outcome patients could go into a respiratory or cardiac arrest so you know that would be the only time we would call a 911 ambulance uh the rest of the time we either use a non-emergency ambulance provider or we transport the patient in our vehicle that's the model that a lot of organizations uh take you know they have a vehicle that has some type of transport capability and might and it doesn't have to be anything special or crazy um it you know could just be a simple van uh you know we use an SUV uh and we have a designated patient area and we have a cage between the driver and the um we have a I shouldn't say a cage I'm sorry we have a barrier between the dve and the backseat passenger in regards to equipment that the care team needs uh you know a lot of places you know have run a whole host of equipment I would say that at the bare minimum you know you you sort of want um you want a first aid kit and you want an AED in case something goes wrong and the patient goes into cardiac arrest while you're restraining them if you have to restrain them um there might be other substances that are involved you might arrive on scene and you might find that the patient's been using opioids and they're overdosed so having the capability to administer Nan sometimes patients May um have attempted suicide and they'll have uh you know they may have uh attempted to cut their risks and you need to provide some type of basic care um some organizations do like a full a Les kit and you know a cardiac monitor in the whole nine yards again a lot of this is based on community need and Community response but it you know some of it can be Overkill too at the same time um police response can become uneven now what do I mean when I say that well you know depending on the officer their experience dealing with patients that are having a crisis or that are having a behavioral health issue uh if they're new and they don't have a lot of experience their interaction with the patient may be different than an officer that has um years on the job and who has um who has considerable experience in dealing with uh clients in this realm some organizations like when you talk about Seattle Police they have specially designated officers that's their job they have additional training they have enhanced training and education in order to work with these members of the community um but in some locals it's whichever radio car is available and again it might just boil down to like this call is in your district and you're going on this call and the training and education that you have may be the bare minimum either offered what's offered in the police academy or as part of your onboarding process um but you really don't have the ability to develop um increased competencies over a period of time the crisis mobile response interaction is just uh in your organization is just uh another call with car Breakin uh you know parking enforcement Etc so you know uh this is just one of the things uh and it's not a complaint against police departments but I think that one of the things that you need to consider is uh you know some of this boils down to budgets Personnel Etc um before this I'm going to play a video that is going to show a police interaction and unfortunately in this interaction um the individual dies so this is Patrick Warren this is from Texas um I'm going to give you the opportunity now you can uh stop the video mute the screen um uh but uh you know I'm just I'm giving you fair warning now so this is Patrick Warren and this is the uh this is from Texas police is the door open hello okay okay hold on man let me let me come okay come on I'm g walk back out I don't work like this me e e I have to come outside there's about six of them in there he came rushing at the door he CL the door on me so I'm just waiting for more units let me see your hands let me see your hands want to CH the point let me see your hands get down on the ground get down on the ground get down on the ground get down on the ground you're going to get t you're G to get tast one taste One Taste lay down on your back lay down on the back lay back I'm gonna shoot you I'm you um I wanted to stop this before he actually uh discharged his weapon uh I could tell you that if we played it all the way to the end um just the emotional response to the officer uh by the officer is really heart-wrenching um you know just to hear his emotions uh at the end um this incident unfolded fairly quickly the officer and this is not a comment uh for or against the Colleen Police Department uh please do not misinterpret anything that I'm saying to be a um to be a comment um about how they should have done how how they should have managed this response or how this response uh could have been managed better but what I will say is that you notice that the uh the incident unfolded quite rapidly the officer made entrance into the home um there were several individuals that were in the home I don't think we saw everybody that was in there uh I don't think the body cam gave us that uh visual uh but there was the individual there that he was assigned to that you know he needed to um you know that he he was uh supposed to um uh find out what the issue was and what the problem was and then uh you know he exited the building you know to a safe place he called for backup you could hear the sirens in the background people were coming to his assistance um and you know he backed up and he tried to create distance and space between him and Mr Warren um he attempted to use a non-lethal force and then uh unfortunately uh you know he had to resort to lethal force and again I kind of stopped it right at the uh you know right where he discharged his weapon but it was a couple of it was a couple of seconds later it wasn't uh you know it was an incredibly long period of time um I mean that incident was like a few minutes but it rapidly evolved to a point where it resulted in the death of Mr Warren um the substance abuse abuse and mental Services health and uh and mental uh Mental Health Services Administration uh samsa is an Administration within Health and Human Services and they've developed National guidelines for Behavioral Health and Crisis Care they've essentially developed the best practice toolkit and what I want to point out to everybody here is that what they have put together is really the essence of a system of care if we look back at EMS EMS evolved from a white paper that was written by the National Academy of Sciences back in 1966 and it sort of outlined this same sort of system of care a single Resource number that people would call specially trained EMTs and paramedics that respond to the scene and then Trauma Centers it was essentially focused on traumacare and in particular motor vehicle accidents I think that out of the entire paper one page was devoted to EMS and it was only 33 pages in length but one page was devoted to EMS and it sort of kind of gave this uh outline of a system of care this is what uh Sams set and their best practices toolkit has kind of come up with so a Regional Crisis call center you know we've seen the 988 number or we should have seen the 988 number uh on billboards we should have heard radio announcements or something on Twitter or X whatever we're calling it this week uh Instagram and the regional call crisis call center first is meant to deescalate patients that are in crisis over the phone and get them the resources and the services they need if they're contemplating suicide and they really haven't formalized it yet but it's also the ability to send a crisis mobile team out um we have been having discussions about this and the uh I sit on the co-responder Consortium and I work with some of the people at Nitsa EMS office and it's you know what's this interaction between 988 911 and dispatch PCH of Crisis mobile response teams the crisis mobile response teams are is exactly what it is it there are teams specially trained to work with patients that are having a behavioral health emergency that are in crisis that are uh In Harm's Way or presenting harm and it's meant to uh deescalate situations get patients to care and services that they require and then the crisis receiving and stabilization facilities are think about it are the the Trauma Centers for mental and Behavioral Health they're the facilities that we ultimately want to bring patients to now realistically um patients that enter 988 through the Regional Crisis call center and and or have an A have access to uh or encounter a crisis mobile team you know those Services have the capability and capacity actually to divert patients from having to be um have their rights taken away and be committed you know they're really what they're really trying to do is get patients the appropriate services that they need not to end up in a waiting room for hours on and or not to be taken to a mental health facility and be locked down for 72 hours but you know try to match patients up with counselors or services that they require um in the co-responder model the reason why the co-responder model works the way that it does is that what we've come to find out over a period of time is that Pat Uh individuals that appear to be in crisis or that are actually in crisis a lot of their issues and problems stem from very basic sort of interventions they need housing they require uh medications uh they're looking for food okay um they are having issues at home with family members who don't understand their mental health condition or with other individuals that they're affiliated with they may be undomiciled the group of people that they are uh you know that they are um staying with or encountering daytoday um don't understand this individual's mental health problems and they may play on that to a certain extent some of these individuals uh have uh substance use issues and they need detox and rehab and they need other care so in the co-responder model by having police EMS and some type of license uh having some type of mental health specialist who can provide care um for these clients that are in need you know we can you know we can address all these issues oh you know can't get your high blood pressure medication let's work on that um this individual is bothering you let's work out a safety plan and the police will interact with that individual and you know they will become the barrier between you and them um you are uh you know you uh you feel very vulnerable um you know you don't care anymore you uh want to hurt yourself here let's work through this issue let's work through this problem and let's get you to a good spot and get you the care that's appropriate for what you need putting together one of these teams can't be approached from a um from a kneejerk sort of reaction and I would caution anybody to think that they could copy and paste something that was going on in the next community and implement it successfully in their Community I think that you really need to you know take a public health approach to this and uh use all the tools that are available to you so the first thing is to do the needs analysis That's essential to providing any type of service in the community health behavioral health whatever the issue is and find out you know what are the problems that you're encountering um how many uh clients are we roughly talking about what are the capabilities and capacities in the community to manage this you could put together the best plan in the world but if you don't have a receiving facility um when you have patients that are in crisis uh you know where does that patient going to end up I mean they're going to end up in the emergency department at your local hospital uh how is that going to work you know we need to work out a better plan with the hospital that's going to receive that uh individual if you don't have uh mental health resources that are available to you and your community what's the tella Health option and who's going to want to uh enter that space you have to remember that some of the individual organizations that are going to step up and look to help help you may not necessar they may have experience working with people with mental health and behavioral health issues but they may not necessarily have experience working in crisis response and or providing Street side care so this is you know this is a a balancing act here um and so selection of who we're going to use and how we're going to employ them is critically important um do they have the uh you know do they have the uh reserve the um their own mental health Reserve in order to deal with patients and crisis remember what I said before you know we sometimes we're on scene with uh clients you know for 45 minutes to an hour uh sometimes it's yeah on average it's two hours and uh some PE some clients it's up to six hours so you know do they have the capabilities and capacities within themselves to do that uh a lot of people that you so not every EMT or paramedic could kind of step into this space a lot of people that come into this uh you know they sort of like that instant gratification you know that they get from treating an asthma or taking care of a patient that uh is having a diabetic emergency because they get to see that they get to experience that real time uh with some some of the with a of a majority of the clients that you're going to deal with you may be dealing with them for years and not that they're in crisis for years but you know you're going to kind of come to figure out over a period of time that you know they're really not in crisis you know but they need more um you know they need more social work issues than they do mental health issues and it's transitioning them over to you know someone that's more appropriate to provide the care that they receive resilience is critically important for your entire team um you know we've done a poor job of this for police fire and EMS in order to manage their mental health but now it sort of becomes Amplified when we pop them into this co-responder model um training we're going to get into training a little bit but training has to be specific um to what they need and again I'm going to go into a deeper dive into that Finance who's going to pay for this uh when they first started paramedics in the state of California they were um the Board of Supervisors in LA county were you know they they just kind of funded it for a year as a pilot program and then it was only after they made an impassion plea um later on when the they wanted the sunset the program that uh Jim paig and the other um you know the other uh Pioneers in the field in LA county were able to convince them this this is worthwhile and you need to continue to pay pay for that um that really pointed out to like a simpler time in the history of the United States where people just did stuff because it was the right thing to do now the first question everybody asks is this is a great program how are we going to pay for it um and then finally you know uh calls and outcomes how do we discuss uh you know how do we discuss successes and challenges um so you know let's talk about some of the Lessons Learned um you know the community uh the community uh assessment the needs analysis is crucial to the success of any program and it's not only the number of patients that you have to manage AG I I mean what if you found out you only had like a handful of patients every month it doesn't mean that you're not going to provide care for them but you might look to do it as part of a regional resource than an individual City resource if you didn't have social workers that wanted to come into the system uh this could be a bigger issue overall um because social workers do a couple of different things one is is that you know they're providing and licensed clinical social workers Mental Health Specialists um you know they're not only providing direct care for the patients but they're also monitoring the temperature of your team they're helping to monitor their mental health as well and in paramedic education I think we'll uh let's talk a little bit about that when we look at the typical entor paramedic they only get a couple of hours of classroom instruction if you're an EMP or paramedic like you know um that you get hours and hours and hours of classroom time and lab time and Ride Along along time where you're taking care of cardiac patients and trauma patients those are the two big categories of patients that we take care of but when we look at when we talk about Behavioral Health emergencies I mean for EMTs it's 15 to 20 Pages for paramedics it's 20 to 30 pages um a couple of hours of classroom instruction on this and then you're done we don't provide any type of clinical or practicum experience out into the field uh New Jersey does an interesting thing they send patients for uh I'm sorry they send paramedics uh that are in The Paramedic program for 12 hours of observation time in a psychiatric unit but you know you're really not observing uh clients in crisis at that point you're observing uh clients that are receiving therapy they're on medications um you might have somebody that's restrained in there but realistically you know you're not seeing the types of patient uh the types of clients that you encounter that are in crisis conversely let's look at the licensed clinical social worker they get six to seven years of education a bachelor's and a master's degree they get clinical rotations on top of which they get a whole host of training that's relevant to their mental health resilience and how to protect their mental health and the same thing goes for psychologists and psych and psychiatrists right you know so uh psychiatrists you know they do a you know they do an internship after they do like their um you know they they do like this uh they do like one to two years of like this General internship where they take care of patients and they get the basics down of being a doctor but then you know they'll go into an you know a psychiatric internship that could be like you know like three to four years all and then they'll sit for their um you know and then they'll sit for their certification exam uh psychologists you know they're getting their PhD in Psychology on top of which you know they go you know psychologists and psychiatrists actually go to therapy as part of their educational process to see how well that they're working and dealing with individuals we don't do that with EMTs and paramedics so a lot of this when we select our teams and we compile our teams together um what is the resilience training that we uh what is the resilience protections that we put put in place for them as part of their training as part of their education as we as they move forward um you know through the program uh do we need to have them you is it a good idea to have an EMT a paramedic and a police officer um or even a licensed clinical social worker on the unit for five years or 10 years I'll tell you an interesting thing I thought for there was a period of time I I thought I was going to get it get out of EMS and I became an investigator for the medical examiner's office and the first uh you know like after I was trained the first response I went on was the unibon case and it was uh um it was a moer uh in West in uh West calwell New Jersey and I met the guys from the behavioral health unit from the FBI you know like I was you know we were like this um uh we were this multidisciplinary team there was somebody from the prosecutor's office somebody from the state police there was me you know the FBI guys and and people from the postal service and talking to the guys from the behavioral health unit I asked them I's like oh wow you know uh this is a great uh this must be like really interesting etc etc and the guy told me he says yeah he says it's like a three-year rotation and then you come out and then you could come back in for another 3 years and that's it and I asked them wow that's you know uh that's interesting um I why do they do that and he said because of the extreme mental and emotional burden that we assume by working these cases uh we can't be in this spot for too long um you know it will it would damage us too much and maybe this is part of the um process or maybe this should become part of the process for our teams how we select people and how we put people into these spots uh he said that this wasn't only limited to the behavioral health unit this was also uh individuals that worked on sex crimes were only in there for you know they did like a three-year rotation then they would come back and then they could come back in again and then the only way you went back back to behavioral health unit was you would go in as in a supervisory role um but you weren't working cases dayt day and again that was a limited time frame assignment so when we talk about resilience for our providers and especially in a corresponder model um the mental health specialists that we pick to be part of the team are better prepared for this but for the police officers for the EMTs the paramedics the firefighters whoever were putting into this role as part of the team maybe we should also consider the fact that we need to limit the amount of time that they spend performing this job uh one of the things that we learned was that a lot of the training um that was provided was originally developed for licensed clinical social workers and uh this was uh developed specifically for them so realistically it didn't address the Gap in education that emt's paramedics and police officers had and so while this training was very informative some of it was over their heads and some of it there there was such a big gap between what was provided and what they were expected to know as a baseline that it was difficult for them to Bridge and so you know we started to parse down into this and I I mean this is just generalized um you uh outline this is not a curriculum by any stretch of the imagination but it is a you know it is a whole host of issues that you may encounter at different times people with postpartum dist uh depression post-traumatic stress disorder um individuals that are suicidal that are homicidal that have um uh you know that that are bipolar uh there's so many different issues that we touch on um you know how do we deal with uh how do we deal with clients that are are that are death there's a variety of different issues that are there how do we deal with uh patients that have dementia um one of the cases that we worked on um that uh came in as a behavioral health issue was a law enforcement officer with early onset dementia um and he was like he was 62 uh and he was walking around and he was uh um punching people in the face and so uh you know that in and of itself is a problem uh but the other side of the coin was he also used to be the boxing instructor at the police academy so when he like punched somebody in the face like they knew it uh and so you know how people interacted with him you know originally this came in as a uh you know behavioral health issue but then you know we you know then we uh you know then we figured it out that he had dementia uh and we were able to manage the call after that um you know we had somebody come from the uh County Sheriff's Department where he used to work and once he recognized the he didn't recognize the person but once he recognized the uniform it gave us a spot to work at UH with them you know Crisis Care has a variety of different factors deescalation techniques uh provider protection protect and evade what we're going to do if we encounter somebody and we can't deescalate the situation or May and we've seen this happen a couple of different times sometimes calls come in to either 911 or 988 and the client is calm but they're having a behavioral health issue and in between the time the unit is dispatched and the time they arrive on the scene other individuals at the scene have escalated the patient to a certain point and now when the team arrives on scene they have to deescalate the patient and in some cases they have to protect themselves and evade and leave the scene uh restraints are not totally out of the uh sit uh out of the uh equation here and neither is and that's either physical or chemical restraints and then documentation clinical practicum this is all part of the education process police officers it is critically important that they have training and more than like this check the box 40 hour sort of training if they're going to be part of the crisis mobile response team but also generalized training like every officer needs training because think about it you may have an individual that has a behavioral health issue but they're calling because somebody broke into their car and so now depending on the interaction between that individual and the officer once they arrive on scene uh if the officer doesn't have any training you could see how it could escalate if he can't recognize that this is you know this person has a behavioral health issue in addition to the fact that somebody broke into their car and this could be there are a variety of different responses that police officers have to go you know have to respond to so you know police officers that are part of a crisis mobile team need really good they need to be trained very well in order to interact and function as part of that team and then officers who are not part of the team need training because patients with behavioral health and mental health issues um call the police for things that are not related to that but they you know that may be a trigger point for them to have uh to have an issue when the officer arrives on the scene in addition to we want those officers trained well because if they encounter the cro crisis mobile Response Team you know if they have better training and a better understanding you know they'll be able to operate in a more efficient and more effective manner with everyone that's on scene you know there's a few different things that need to go on you know there's the dispatch to the scene who's doing that is it 911 or is it 988 uh it's the scene size up right so you know some of the first things we're trying to do is identify routes of ESS um you know what are the danger signs uh you know we had an incident not too long ago where a guy was running around with a samurai sword that was you know that was sort of easy to figure out that was a danger sign but you know some things you know might seem innocuous uh we had an incident not too long ago where um an individual had his backpack and he had a handgun in there so you know Rec you know recognizing you know danger and potential things for danger and then obviously deescalation protect evade and and escape and then restraint chemical restraint and uh physical restraint uh our assessment is very basic on the EMS side um you know we don't go in there and take and take a lot of Vital Signs essentially we go off of mental status so you know we look at is the patient alert and oriented times three and a lot of people mistake that for decision making capacity that is in no way indicative of decision-making capacity that has to show that the patient is oxygenating and profusing their brain well and then we talk about decisionmaking capacity and we talk you we talk and that's an interactive uh interrogative approach determining whether the patient has decisionmaking capacity questioning the patient you know do do you understand what's going to happen Etc and having the patient explain it in their own words not yes or no answers but being able to explain it and then skin signs obviously you know if they you know if somebody is pale and moist um that might point to like a profusion issue it might even point to some type of substance use issue and then everything else is based on you know do we have a need to do a physical exam uh you know does the patient have a history of diabetes maybe he might be hypoglycemic um you know if he's if his spo2 is 76 he might be uh in this state that he is because he's hypoxic so you know everything else kind of unfolds after that uh dispatch operations you know we try to uh figure out is there a History of Violence or is there act of violence being reported from the scene so you know if somebody's running around with a baseball bat smashing windows or if the client has a history of violence with First Responders or mental health professionals um you know we might uh uh we might defer response and let it go to law enforcement or respond with a a larger law enforcement presence and then um you know try to Mi uh try to mitigate it while we're on scene with law enforcement providing protection or um trying to manage it inter actively with the police trying for the best outcome possible and a lot of this goes back to training working um you know uh working with law enforcement uh not only on scene but scenari based uh training opportunities where we could kind of work through issues and problems ahead of sign ahead of time um you know when we see red flags we want to leave this seen immediately um and you know some of those things are not necessarily they may not necessarily be specific to that patient if you have somebody that's undomiciled and they're in an encampment of other individuals it may not be safe not because of the individual but because of the other people that are on the scene so you know these are all things that we need to take into account um some providers wear uh uh stab prot protected uh a vest that will provide protection uh from penetrating wounds or from gunshots um you know this is an entire uh process that we wrap ourselves around some people feel that wearing the vest uh provides a barrier or it changes the tone or tenor I would say that wearing enhanced protection capability is dependent on your needs analysis the clients that you're encountering and issues that you've had with violence against providers in the in the past if you look on that cabinet that one vest up on top there it actually has a panic button that goes like right to the police department um and many of of these uh many of these teams if they don't have a police officer embedded they have a police radio and then some teams are actually providing self-defense training limited self-defense training I mean that's the last thing you want to do is really go toe-to-toe with a P with a patient you know you really want to try to deescalate the situation um if need be protect evade and Escape if they come at you and then the last thing is self-defense if you have no other choice but this is a really small number of patients that we encounter at this point uh when we talk about restraint it's who when why um medical restraint is different than law enforcement restraint um anytime a patient has a history of drug or alcohol use it increases the chance that the patient is going to have a negative outcome and going to Cardiac Arrest whether it's physical or chemical restraint if the patient has been using drugs or alcohol then physical or chemical restraint should be avoided um unless there's no other option and again you know it's a roll of the dice at that point uh when we talk about uh when we talk about law enfor when we talk about law enforcement restraint you know you have to remember that a police officer when they're looking uh to restrain somebody um you know they're trying to uh temp arily limmit the freedom of that person um and especially if they're being un uncooperative it's you know you're coming into custody we're going to place you in restraints you're going to go into the back of the uh radio car and then when we arrive at the uh when we arrive at the facility um uh when we arrive at the facility um we are uh you know you're going to you know you're going to go into uh protective custody uh either into a cell or some other uh some other situation like that um on the other side of the coin um medical or behavioral restraint right is different and that um we do this because we want to prevent patients from hurting themselves if you're an EMS you anytime you carry a patient you restrain the patient right you put their you know you put you put straps on them to hold them into the stretcher or into the St a chair to hold them into the cot um you know you know these are the you know these are the things that you do in order to keep them safe um if they're having a mental health crisis right we do this to prevent them from injuring themselves or other or other individuals so we restrain people you know all the time um when we have patients with dementia um you know we may restrain them in order to perform a procedure on them to start an IV Etc um you know I've cardioverted patients and I've restrained them uh because they you know they have a tendency to try to reach up with their hands and grab you at the same time you're cardiov verting them um and that's not like a good thing to get shocked at the same time that the patient is getting shock um sedation some clients may need to be uh sedated and this is when deescalation techniques are not uh amenable to this individual um we have a couple of different substances at our disposal one is uh ketamine uh which has become very controversial for a variety of different reasons Elijah mlan was a young man who had um uh he uh he had asper burgers and he was stopped by the police um but he became agitated because he didn't understand why he was being detained and so um when the police called for the paramedics they wanted him chemically restrained and chemical restraint is not a law enforcement function it is a medical function and the paramedics uh not only chemically restrained him at the behest of the police department but they also used an inappropriate dose so you know there's like a malpractice component that goes with this uh currently these two paramedics are being charged with homicide um I do not have all the details of the uh of the case surrounding Elijah mlan but I've seen the video several times it is quite disturbing and is quite upsetting that this poor young man uh passed away but again a chemical restraint is a medical procedure it is not a law enforcement procedure um and if anything they probably should have made contact with their base Hospital uh San Francisco fire department has sedated 4,000 people in in LA in in less than 5 years um this was extremely disturbing to me when I first heard this uh because first of all uh you know the medication that they use is a control substance and um uh thank you very much for that somebody told me that Aspergers is not considered a diagnosis any longer it's an outdated phrase that the autistic Community is against its autism thank you very much I I I appreciate that um uh the uh San Francisco Fire Department uh is uh being sued currently uh because of a uh of an incident at uh after Warriors game where they sedated a woman uh who they said was um that was in crisis and uh you know from bystanders and from the woman's own description um you know she wasn't you know she wasn't in you know she was was in crisis um she was uh she was upset and the exact nature of her being upset is hard to sort of uh was uh difficult for me to discern but um hearing the description from bystanders and from the patient that she need to be sedated I I don't know I don't know I don't think that she did but again you know this is um anecdotal uh this has been related to me anecdotally but 4,000 people in less than five years in in less than five years to me seems like an extremely high number uh because in my program we've been operating at two years now we haven't treated 4,000 people but we haven't sedated anybody and the number of individuals who we've had to put a 5150 hold on where we take and a 5150 hold in the state of California means is that you are a danger to yourself you're a danger to others or you don't have the means or capability to protect yourself and then for 70 we could place a uh 5150 hold where we would take you to a facility and they hold you for 72 hours and then uh at that point at the end of 72 hours they could go before the court and extend it for a longer period of time um there have been cases uh where people have gotten a 5150 hold and they were released after 2 hours where they were deemed to be safe after they were evaluated by a um a psychiatric professional but to get back to what I was saying um we haven't sedated anybody um in the two years that we've operated the program and we cut our the number of patients we put on a 5150 hold uh before our program was operated by the police department and now our program is operated by the fire department with um emt's paramedics and a tele Health option and we've cut the 5150 holds down by uh 70% so um you know when I hear like you know you you sedated 4,000 people in five years it gives me pause and you know that should be under review by the EMS agency and by the medical director um there's a couple of uh different medications that can be used for Sedation and chemical restraint um you know patients that are having paranoid thoughts Etc um you know uh we can give them Al lanzapine and essentially uh it's a little it's a little foil film you hand it to them and you know they could pop it in their mouth and it just dissolves under their tongue um we have ketamine but we can't use it uh for chemical restraint but other organizations do use it for chemical restraint the medication that we use for chemical restraint is mazam um but you know generally these are the medications that you uh you know that you see being used in the prehosp care environment um the last couple of things I want to talk about here is number one is Success what does program success look like uh it has to be uh well Quantified uh and for us when we first started the program we wanted to reduce the number of uh clients that were going to be restrained and we wanted to reduce the number of clients that were getting a 5150 hold um talking to other places across the country I was talking to uh some officers in Texas and I'm not going to name the the city that they're from but they related to me that um you know they would have they would have to take care of Behavioral Health and emergencies just as if they would if they were had a car break in ETC they didn't have a specialized officer that was dedicated to that and one of the problems that they had was was that um you know calls would back up in their area and they were under a lot of pressure to clear calls so if they couldn't get resolution within a short period of time they would put patients on a psychiatric hold and that was the only reason that they did it um and we see the same thing in California and other Loca you know and other locations where uh police officers have that uh capability you know it's that calls are backing up um you know I can't get resolution to this so I'm going to put the patient on a psychiatric hold and now it's the hospital's problem and they have more time to deal with it so you know one of our things that we looked to do was that we wanted to reduce the number of holds that we put on patients and get them appropriate care you know that was one of our measures and then um and then the uh you know then the other measure uh was we're looking at repeat clients you know how many clients do we have that are repeats that are not you know not necessarily in crisis but now you know need to be transitioned to other care providers within the Health Care System it's really important to identify to have definitions for your program uh both for uh operational sort of issues um you know so we have like a whole host of definitions for um uh you know uh uh formally uh incarcerated individuals who have a History of Violence um you know undomiciled individuals you know we have a whole host of definitions uh that we uh that we look at the uh operational um the operational issues and operational definitions of previous History of Violence on scene um you know previous History of Violence by uh other individuals on scene not necessarily the client so you know we have a whole host of definitions that we uh sort of work through uh what are the resources and the resources are not only you know the crisis receiving facilities that you may transport patients to but you know we have Behavioral Health counseling that we get clients into and it may not they may not be able to get in instantly they may not you know we may not be able to take them directly to the scene but uh from the scene they might have to wait like an hour to till they can go see a counselor uh if we don't take them sometimes we'll go back and take them but if we don't take them how are we going to get them there you know what's the Uber resource when a a client needs medications we had a a lady that she didn't necessarily need medications for her mental health issues she had that she didn't have her blood pressure medication and she was really worried and she was really concerned and so what were like the 24-hour pharmacies that were open on Christmas literally you know so what are the resources that we have what are the resources that you that you need in order to be a success and in some locals it might be easier to put these together than others but you know you need a list you need to put that together uh who are the stakeholders uh so it is not only the hospitals and the emergency departments and the police and EMS and the behavioral health uh Institute you know it's the behavioral health institutions it's the schools a third of all our patients are children under 18 and a third of our respons es occur at schools that may not occur to you but they're a valuable stakeholder and this entire uh in this entire proposition and then don't forget the patients make sure that they have a voice in your processes in the services that you're providing and then trying to Define what your outcomes are your outcomes may become U more granular As you move forward uh the two most important things mental health resilience protection for all your providers on your team and also a mental health resilience officer uh New Jersey actually passed the state law that every police department has to have a mental health resilience officer and then they have a chief mental health resilience officer in the um in the Office of the Attorney General and so uh you know I think that every agency even if you're not doing crisis mobile response if you're an EMS agency if you're a fire agency um you know uh every police department they need a mental health resilience officer and especially if you're operating Community Paramedic program or a crisis mobile team you know you need to have a mental health resilience officer as well so I think so our challenges for the future are the systems of care building them out especially in rural in suburban and Rural and Frontier areas uh training going from competence to competency because you know as time goes on we want our providers to be better at providing care and then the interface between 988 and 911 um some calls may end up at 988 and may be a 911 call phone call some phone calls may be a 911 phone call and end up at 988 so how that works um I just have like a little bit of stuff here from LA County but I'm just going to kind of go through this um another short article um that kind of talks about a lot of what I spoke about here uh you could click on that and then um I I I think that I've gone over but um I'm ready to uh I'll I'll take any questions I'll entertain any questions that anybody has right now okay so the first question I have can you explain the desire to move from competence to competency sure um competence is when we determine that somebody's competent you know they're they're essentially safe to enter the field and provide care competency is the skill is the skills and knowledge that you acquire over a period of time from uh client interactions that make you that as you move from an apprentice to journeyman to a Master clinician so you're building a greater competency over a period of time uh if you go to a cardiac surgeon and you're going to have a cardiac bypass you know do you go to the guy that has done it a hundred times or do you go to the guy that's done it a thousand times and the guy that's done it thousand times what are his outcomes how are his success so we can identify those providers there's a uh there's a lady that I know she's a licensed clinical social worker she's absolutely one of the best she's got like 25 years in the field and um and her capabilities and her knowledge you know have evolved over a period of time but she told me that when she first entered the profession uh she was working in Los Angeles at the county hospital and she said she was absolutely Dreadful and she went home every day and she cried because you know this is what she really wanted to do but she didn't think she was good at it so but you know but you know she had taken her certifying exam she had passed all the tests she had passed her in-house training and she had that competence but she built this competency over a period of time that you know really made her that much of a better provider I hope that answered your question Alexis uh Danny you want to talk uh a little bit on uh what's kind of the latest state of play because it's been a while since uh we looked at it uh on integration of 988 and 911 is there is there much out there on that there's actually a there's actually a greater push for interaction as a matter of fact uh Kate Elkins who is at nits EMS and she's like the 911 Guru for nit EMS she's actually making a big push for um uh a conference in February that she's going to push out to to really kind of discuss and work out the 911 988 interface a lot of times uh what we're seeing is in a lot of parts of the of the United States um you know there's no capability to shift the Annie or the patient information over from 911 to 988 or 988 over to 911 and you might say like that's not a big deal well when you're trying to find somebody that's in crisis knowing where they are is really really important and you know having the Callback information and so people are kind of building these um ad hoc systems amongst themselves plus the other side of the call uh the other side of the coin is is the screening the 988 people are Dynamite at helping people that are in crisis and parsing through their problems but now if they have somebody that's a diabetic that might be a little bit harder lift for them and then getting that information you know providing the appropriate call screening and then getting it over to 911 um might be uneven at best and conversely on the 911 side you know identifying patients in crisis um some locals that have a um that have been doing this for a long period of time and I'll say like San Francisco um Boston is another one you know they they they do a better job they're not perfect nobody is but they probably do a better job than you know other communities that um uh you know that that don't have that same level experience okay um so this is the point uh folks when we can start putting questions into the chat um and so uh as we're waiting for those to come in uh I just want to kind of expand on that in terms of the 988 uh kind of uh landscape a lot of these are were pre-existing right crisis hotlines um and so as you talked about the the Annie alley but the technological uh sophistication of a 911 Center versus a crisis hotline are you know usually vastly different and so um uh so there is a lot there in terms of how they're going to be uh more closely integrated which was clearly envisioned with the formation of 988 but that was a kind of a national you know high level Vision that wasn't necessarily tied into uh you know the reality on the ground in a lot of communities right it's it's probably I guess tan amount to uh looking at you know the adoption of 911 for the first time uh and and how long it took communities to take on 911 and how dispatching was done pre- 911 versus post 911 right and some of these things there literally a you know it's a it's a multi-line phone you know uh notepad and a pen you know at the low end right um and so uh there's a lot there so that's that's interesting on the the Nitsa the the conference Dan keep us posted on that and maybe we'll we can send that out yeah no absolutely and it'll and um Dr Jennings it'll be a one dayer down in DC so you know I mean if you if you had the you know the opportunity to take the train down or whatever um I don't know if there's going to be an online option but um you know it might be something for you to go down and I'd be happy to make that introduction with you and uh Kate Elkins uh you know the I I mean the funny thing with 988 and 911 I don't know of any non-governmental provider I I don't know if any um non-governmental p app let me put it to you that way I know that some people have contracted out um 91 uh screening and dispatch services but I don't know of a 911 Pie app that's provided by a private provider you might have better information on that but on the 988 Side by and large um overwhelmingly you know it's these folks that have been doing uh you know suicide hotlines and crisis uh call screening for um time in Memorial by and large yeah and uh you know 311 may be of interest there too just as a potential model because a lot of communities have kind of figured out the 311 911 integration but again those tend to be uh public right as you as you said it there may be out there but I don't know if any privately run 311 cters uh either so well you know and that's an interesting thing you know I never even consider 311 because I you know we you know you see it now calls end up on you know for locals that have 311 Services we see calls that end up at 311 that are eventually 911 calls and conversely we see the 911 calls that are really 311 calls and but now you know if we enter that into the mix you know you could have a uh you could have a uh client that's having a a mental health issue um that may end up at 311 and and uh making sure that that call gets directed appro Le is key okay um I see we've got uh Paul Maniscalco on the uh on the line I don't want to put him on the spot if he wants to jump in with anything but um not hearing any questions um I'm just G to ask in terms of the uh you know composition of the teams and uh you know uh the kind of capabilities and and protective in terms of you know you talked about the radio um kind of being the minimum equipment to be able to have a direct contact with police if you're going out there have been a few Adverse Events where some of these teams have gone out and gotten into trouble um and and you know what are your thoughts on that in terms of the the challenges uh for in this I think in those cases it was 911 dispatchers um trying to trying to make those decisions or protocols on a behavioral health you know response uh you know for the team or is this a more traditional law enforcement response I a lot of that is dependent on the local that we're talking about so when we speak about places like Los Angeles for instance their dispatchers have a lot of experience in this world working through these issues um Los Angeles used to be an npds City and a few years ago um Mark Xin the medical director there dropped uh mpds for their own system which they felt was better and so they you know they have the um they have the uh the the knowledge skills and abilities uh that they've developed over a period of time to sort of figure this out in other locals many places are resorting to the mpds uh call screening rubric which has uh depending on who you talk to has varying degrees of success and some people are extremely happy with it and some people feel that it's um you know it's been less than Stellar to meet their uh to meet their needs uh you know the reality of this is that as more organ ganizations start to move into this realm and they are standing up and I think most of the 988 call centers have been stood up but everyone is still trying to feel their way around the edges in regards to this and so you know you're trying to make the transition now from before that if you had a behavioral health emergency you dispatched the radio car and you know that was it you know you waited for the officer to get on scene you know and now um if you're not using uh mpds and I don't know if appco I know that appco and Power phone and um I can't think of the other one off the top of my head um I know that they have uh you know call screening algorithms I don't I don't know how good or how bad their uh Behavioral Health uh call screening algorithms are but the other side of the point is uh a lot of communities across the United States either due to cost or other considerations um you know don't Embrace these uh call screening tools some do and they you know they leverage them to uh to be very effective uh but I think that as you move into this realm it might be the impetus for these communities to kind of adopt those call screening uh Tools in order to facilitate getting the appropriate res resource to the appropriate patient okay um I think based on the the questions and the time and uh I see a couple people starting to uh drop out I think we can wrap things up uh Dan I think it was obviously was a great talk uh a lot of information um I really appreciate your uh expertise uh on this and you're kind of global uh you know from the high level down to the the the the the nitty-gritty uh and so thank you for that uh when this project uh gets finalized we'll certainly communicate that out um and uh I've got a question uh here about a certificate um I will address that uh offline and uh with that I'd like to thank everybody for attending and thank you Dan for your uh you know a great talk oh not to worry thank you very much oh let me hit stop sharing here I'm sorry I was okay and and we'll be back in in probably in February um you know we'll start the series up again so everybody have a uh a good and safe holidays and uh Happy New Year and we'll we'll see you then so uh thank you very much