Crisis Center

Summary

Establishment of a behavioral health crisis center, sometimes referred to as a crisis stabilization center, to be operated by Oaklawn Psychiatric Center, open 24/7, 365 days per year.

Goals

• Improve the quality and quantity of health care provided to individuals in behavioral health crises
• Unburden first responders, law enforcement and emergency department personnel from managing behavioral health crises
• Reduce the cost of managing behavioral health crises

As is typical across the nation, our current mental health system relies primarily on two types of services – outpatient treatment and inpatient hospitalization. In St. Joseph County, outpatient treatment is provided by Oaklawn and private providers, and inpatient treatment is provided primarily by Memorial Epworth.

While physical health has outpatient, inpatient hospitalization, and urgent care, behavioral health systems don’t have the equivalent of an emergency department or urgent care center. Inpatient hospitalization requires that someone is suicidal, homicidal, or gravely disabled. People experiencing a mental health crisis may fall short of these criteria, but their need is more acute than what outpatient services can accommodate. The crisis center will strengthen several existing partnerships, including primary care providers, service organizations like homeless shelters, hospital emergency rooms, and local police departments. All will benefit from the new center, which will provide a level of care that is not currently available in St Joseph County.

In early 2019, Faith in Indiana leaders, Sheriff Bill Redman, and senior Oaklawn staff started meeting monthly to find solutions to the gaps in mental health services in our community. They consulted with national networks and leaders in the field who are working on these issues. Sheriff Redman initiated a mental health liaison officer as a significant start. Later in 2019, Oaklawn convened a broader range of community partners through its Trauma Informed Recovery-Oriented Systems of Care (TI ROSC) initiative to continue and expand the conversation. Partners included the South Bend Police Department, Probation, addiction and recovery networks, physician groups and hospitals, the Department of Health, the Sheriff, and faith leaders. The team met quarterly with four taskforces meeting more frequently to assess existing services, gaps, and solutions. Particularly helpful was consultation with Dr. Margie Balfour and her staff, national leaders on crisis response, who shared their learnings from nearly 20 years of work in Arizona. Balfour is the chief of quality and clinical innovation at Connections Health Solutions, which operates the Tucson Crisis Response Center. This research and the review of other models has advised the planning for our local crisis center.

Consensus developed among the TI-ROSC partners that an integrated system of mobile crisis teams and a crisis center would be the most effective way to address unmet mental health needs and serious gaps in our behavioral health infrastructure. Additional background and supporting documentation can be found in the documents/hyperlinks below:

1.  Cops, Clinicians, or Both? Collaborative Approaches to Responding to Behavioral Health Emergencies 
2.  Roadmap to the Ideal Crisis System 
3.  INBHC Report 

Faith in Indiana organized a public assembly at Potawatomi Park in May 2020 which was attended by 325 community members. Sheriff Redman, Oaklawn CEO Laurie Nafziger, Health Officer Bob Einterz and County Commission President Andy Kostielney agreed to pursue planning, funding and implementation of a crisis center in St. Joseph County. American Rescue Plan (ARP) dollars were seen as a promising avenue for getting this effort started.

In pursuit of ARP dollars to launch this service, the SJC Department of Health served as facilitator of the project and convener of a crisis center advisory group consisting of key stakeholders including leadership from Oaklawn, Beacon, County and City law enforcement, the mayor’s office, 911 and Faith in Indiana. Representing these groups, the SJC Department of Health submitted a proposal in June 2021 for the crisis center during Round 1 of ARP funding. The County awarded $2.66 million dollars for year one in December 2021 and encouraged the Department of Health to request additional funding from the County in round 2. The advisory group has been meeting monthly since January 2022 to further plan the design and implementation of the crisis center. The agendas and minutes of these meetings are available upon request.

Initially, Beacon Health System, specifically Memorial Epworth was the operational lead on the project. In September 2022, it was determined that Oaklawn is better positioned to operate the crisis center in close partnership with Beacon/Memorial Epworth. A key reason for the change is that the project could be more cost effective under Oaklawn’s license without some of the regulations that come with hospital licensure. Under Oaklawn, the center will be licensed as an outpatient department.

We are now working toward a system that includes someone to call, someone to go, and a safe to place to go.

• Someone to call. The state-wide 988 system and the SJC 911 system can now automatically transfer calls to Oaklawn.
• Someone to go. A mobile crisis response team funded by Oaklawn can travel to someone in the community in crisis, 8 a.m. to 8 p.m., Monday through Friday. There are plans to expand hours to provide 24/7/365 care.
• A place to go. Crisis center, in addition to existing outpatient and inpatient programs.

The crisis center will fully integrate into Oaklawn’s extensive continuum of care ensuring that people have access to high quality care when and where they need it.

See graphic: “Crisis System – Alignment of services toward a common goal”

The main objective of a crisis center is to stabilize the person in crisis and triage them into the appropriate level of care as quickly as possible. Crisis centers reduce the need for emergency department visits and jails as a holding cell. Crisis centers also provide a better, and less expensive alternative to an emergency room visit, and employ staff who are best trained to manage mental health crises.

The center will utilize a 14-chair living room model, offering a safe place for adult individuals to engage in stabilizing treatment.

Services will be provided by a team including social workers, peer coaches, case managers, nurses, and prescribers. The site will integrate with the mobile crisis team and utilize the existing on-site pharmacy that Oaklawn hosts and environmental and nutritional services through Beacon. Translation services will be available to link to ongoing outpatient treatment offered by Oaklawn and Beacon, including Oaklawn’s low barrier Open Access.

The crisis center will be available to any adult individual seeking help, regardless of diagnosis or insurance status. Oaklawn will ensure culturally competent and trauma informed approaches and ensure policies reflect this approach.

Oaklawn is taking extra effort to partner with first responders in planning to ensure a collaborative response when first responders interact with the Crisis Center. This approach – to collaborate and not turn away individuals brought in – will be accomplished through the following:

• A separate entrance built for first responders who are bringing in an individual
• Policies that support collaborative efforts with first responders
• A marketing campaign so the community is aware of this new service
• Training incorporated into current Crisis Intervention Training (CIT) provided to law enforcement to ensure officers are aware of the benefits and uses of the Crisis Center
• Frequent communication and follow up with our community first responders
• The ability of the mobile team to dispatch to calls from first responders and transport individuals to the crisis center.

Services will be provided through a culturally competent and trauma informed lens. The following services will be offered at the center:

• Comprehensive risk assessment (including harm to self and others) to evaluate level of need
• Mental health and substance use assessments to clarify diagnosis
• Safety planning
• Psychosocial education
• Prescription services
• Basic medical screenings (vitals, drug screenings…)
• Assessment and initial treatment in the least restrictive setting with linkages to inpatient and detox centers when clinically indicated

Oaklawn will utilize screening and assessment tools upon admission to the Crisis Center to determine the level of risk to self or others. There will be metal detectors and a safety assessment to ensure the safety of all. Treatment response will correspond to level of need. Oaklawn will not turn away individuals because of past or current justice involvement.

The physical layout of the facility combined with the Crisis Prevention Institute (CPI) trained staff will support the safety of staff and individuals in the center. The living room layout of the space will provide staff a direct line of sight to individuals, except for when they are in the bathroom, designed to follow all necessary safety requirements. Some of the chairs will have barriers around them for individuals who will benefit from a reduction in stimuli. There will be tables and chairs for conversation and a private office for calls or confidential work.

For individuals who are unable to deescalate, Oaklawn will use the onsite Crisis Response Team who have received extensive training in the CPI model. This team is a multidisciplinary team trained to respond and deescalate individuals in other Oaklawn programs.

When all other methods have been employed and there continues to be a threat to an individual or staff, Oaklawn will call a CIT-trained police officer for additional support.

Oaklawn currently works with law enforcement on these complicated cases and feels that collaboratively, we have the right working relationship to keep individuals safe and get them the care they need.

Oaklawn and the crisis center’s advisory group will continue to engage in a multi-level plan to ensure the sustainability and longevity of crisis services. It is imperative for Oaklawn, and the institutions and organizations represented in the advisory group, to demonstrate the effectiveness of the center through outcomes and engage in targeted activities at the local, state, and federal level to secure sustainable funding.

Local Level

Oaklawn will monitor and evaluate outcomes to underscore how dollars invested into the crisis center will translate into dollars saved in budgets for St. Joseph County, the City of South Bend, local police agencies and local hospitals. Oaklawn will report the results of its monitoring and evaluation effort on a quarterly basis to the advisory group

State Level

Oaklawn will continue to partner with the Indiana Council of Community Mental Health Centers and The Indiana Department of Mental Health and Addiction (DMHA) to create and operate a fully functional behavioral health crisis continuum. Central to the creation of this continuum, Oaklawn will continue to partner with state leaders who are aggressively pursuing a Medicaid prospective payment funding system (PPS). This PPS funding system would include a reimbursement structure for mental health crisis response currently not supported by Medicaid. Indiana’s DMHA is actively engaged in planning for crisis services to be reimbursed by 2025.

Federal Level

Oaklawn anticipates funding from a federal Substance Abuse and Mental Health Services Administration (SAMHSA) grant through 2024. This grant will fund the crisis phone line and mobile crisis response teams.

Why 14 chairs?

We used the experience and counsel of well-established crisis centers to calculate the number of chairs needed for the center. The formula considers the population, available community services and typical length of service. Based on that data, we believe 14 chairs will meet the needs. Remember, most situations are resolved in a matter of hours.

Will Oaklawn accept indigent patients?

Oaklawn will accept all adults, regardless of their ability to pay, which is consistent with policy and practice.

Will Oaklawn help pay for medications?

Oaklawn offers a prescription assistance program and uses their Foundation funds to cover individual medications. Further, assistance is provided to enroll in health insurance.

Is someone required to leave after 24 hours?

While most situations are resolved within a few hours, we will not discharge someone based on the clock. As we assess the crisis and risk, we will identify a plan of care and work to utilize other community resources to ensure the patient leaves with an appropriate plan of care.

Appendix A

Floor Plan

Appendices B & C

Timeline & Outcome Measures