Prepared for NAPAS by
Center for Public Representation
Northampton, Massachusetts

What are the basic elements of a crisis intervention system to prevent unnecessary admissions to an institution?

1.     Capacity to provide crisis intervention services

    A comprehensive crisis response system includes five service models:

    (1)    Emergency telephone response - area wide, accessible telephone contacts with skilled crisis intervention workers who can screen requests and respond with counselling, support, or other telephonic interventions. This component is often referred to as "hotlines" or "warmlines" and also include information and referral.

    (2)    Mobile outreach - a team of trained crisis intervention workers who are available to visit a person in her home or other setting where the crisis occurs, to provide counselling, support, and other interventions on-site, to conduct an initial assessment and determine whether additional on-site support is appropriate, and to remain with the individual for as long as necessary until the crisis subsides.

    (3)    Evaluation - formal assessment to determine what ongoing services, if any, are appropriate, including additional in-home supports or interventions to address the crisis without requiring the individual to leave her own home or other setting. In many programs this capacity is provided as part of the mobile intervention program, in order to avoid the unnecessary dislocation of the individual to a centralized clinical site.

    (4)    Crisis residential setting - a specialized, staffed environment where an individual can live for a brief (usually up to seven days) period in order to be provided with intensive support and intervention outside of the individual's home or other location where the crisis occurs.

    (5)    Respite residential program - a residential program which

provides residential support, usually for up to one month, if a longer residential alternative is needed then a crisis residential program.

    Each of these five service models can be staffed primarily by consumers, although some licensed professionals are needed to make clinical evaluations. Most importantly, the evaluation and residential services should be provided outside of a hospital, in more integrated community settings, with appropriate staff.

2.    Standard

    Most states have a statutory or regulatory standard for emergency detention or involuntary admission to its mental health or retardation system. Since these standards define the criteria for involuntary admission, it is appropriate for there to be a different, lower standard for crisis intervention services, particularly because these services are offered on a voluntary basis. Conversely, it is reasonable to establish even more rigorous standards for involuntary hospitalization when crisis intervention services are available.

    Once a community service system has established an adequate array of crisis intervention services, there should be a significant decrease in involuntary admissions to psychiatric or retardation facilities. The capacity not only diverts unnecessary admissions but it also can prevent involuntary treatment which otherwise might have been required under existing statutory or regulatory standards, in the absence of an effective crisis response network. Therefore, states should narrowly define the criteria for involuntary institutionalization after a crisis services have been utilized.

3.    Process

    Similarly, states' statutory and regulatory mechanisms define the procedures for involuntary admission to psychiatric or retardation facilities. Usually certified clinicians can involuntarily admit an individual to a public or private facility if the statutory standards are satisfied. Further review of this clinical decision is not usually required. However, once a comprehensive crisis network is established, it is appropriate to limit the authority to involuntarily admit an individual to the staff of the crisis assessment program. It is also reasonable to subject the admission decision to further review by the public entity which funds and oversees the crisis system, in order to assure that the evaluation and admission decision is consistent with the more rigorous standards described above. Frequently, administrators from county or regional public entities which fund and operate the entire community system have final review and approval authority over admissions, as a safeguard to minimize costly inpatient utilization.

4.    Funding

    Traditionally, funding for crisis programs, other community services, and institutions were distinct. Many states are now experimenting with unifying the funding so that community programs, and particularly crisis intervention services, are financially responsible for inpatient hospitalization or other costly institutionalization. This fiscal disincentive to transfer a person to a more restrictive setting has been extremely effective in encouraging crisis response systems to address and resolve the crisis without the need for segregated inpatient treatment.