Erin Dalton painted a grim portrait at the kickoff meeting of Allegheny County’s starkly named Crisis Response Stakeholder Group.
“People are cycling through our crisis systems. Our emergency rooms. Our homeless system,” Dalton, then a deputy director of the county Department of Human Services, told a Zoom room full of government and private sector officials, according to her slide presentation. County data identified 763 people who frequently faced mental health crises. Nearly three-fifths of the people who cycled in and out of the jail were getting mental health services.
Dalton, who now directs the department, asked the group how the system tasked with handling behavioral crises might be redesigned.
That was September 2020. Fourteen months later, the county is taking the first steps in what it hopes will be a comprehensive redesign of the way behavioral health problems stemming from mental illness, substance abuse and poverty are handled.
This month and next, the department plans to ask for proposals from service providers that would:
- Show up at the scenes of behavioral health crises and provide help
- Assist police in diverting people with mental health problems from the criminal justice system to social services
- Provide short-term housing for people who are experiencing worsening mental health or substance use symptoms
- House people who are released from jail and who have mental health needs.
The department is also preparing for the local rollout, next year, of an emerging national 988 suicide prevention hotline, which Dalton hopes will absorb some of the behavioral crisis-related calls that now go to 911.
UPMC’s resolve Crisis Services is likely to remain an important part of the behavioral crisis system, according to Dalton, despite criticism of it during the stakeholder process.
Dalton said she hopes that in the coming years, people facing mental health crises will be less likely to face arrest or incarceration, and instead “more often than not … get the kind of response they need and can go on with their lives.”
‘Diving into the gaps’
The county quietly created the stakeholder group three months after the murder of George Floyd by a Minneapolis police officer. That killing ignited protests and energized debate over law enforcement’s handling of incidents driven by poverty, mental health and substance use.
“This is a point of crisis, but it’s not a new crisis,” and it has evolved over recent decades as mental health care has shifted from big psychiatric institutions to community settings, Dalton told the group at its first meeting, according to her slides. The county convened 30 people – county and City of Pittsburgh officials, police chiefs, philanthropy executives, nonprofit leaders and academic researchers – in hopes of addressing a question Dalton posed: “How can we use the moment of crisis to improve care?”
PublicSource used the Right-to-Know Act to get documents detailing six months of closed-door meetings of the stakeholder group. In an interview and a written overview, Dalton and her department’s Manager of Special Initiatives Jenn Batterton then described the emerging plan to redesign the system.
A behavioral crisis, according to the stakeholder group’s definition, is an incident in which emergency services respond to someone’s mental health distress, substance use, intellectual disability including autism, or homelessness.
Since 2007, the job of responding to many such incidents has fallen to resolve Crisis Services. That UPMC unit gets around $1.6 million from the county, plus reimbursements from the state and private insurers, to provide mobile crisis response teams, a walk-in center and short-term residential services for people with mental health emergencies.
In October 2020, a resolve official told the stakeholder group that there was ample communication and collaboration between that organization and law enforcement. In later months, though, stakeholder group members called resolve “not useful” with a walk-in center that was an understaffed “dumping ground,” according to the documents provided to PublicSource. Some said resolve’s mobile teams take “forever and a day” to get to people in need and then “simply leave” if the person in crisis is uncooperative.
“I think we do very well,” said Dr. Jack Rozel, resolve’s medical director, in an interview Wednesday with PublicSource. “We have mobile crisis teams dispatched more than 70% of the time within an hour, en route.” Given the volume of calls, walk-ins and mobile crises, he said, resolve staff handles matters effectively the vast majority of the time.
When people got into the mental health treatment system, the diagnoses and treatments provided were skewed by race, the stakeholder group learned.
Dalton told the group that white clients of the behavioral health system were much more likely to be diagnosed with conditions like anxiety and addressed with outpatient care and medication-assisted treatment. Black clients, by contrast, were more likely to be diagnosed with schizophrenia, schizoaffective disorders and adjustment disorders, and to be involuntarily committed for care.
By February, the stakeholder group developed 16 broad recommendations, meant to improve outcomes by preventing crises, intervening earlier, handling scenes differently and providing services afterward.
“That’s when all of the work had to start, even though, obviously, the [stakeholder] process was important — extremely important,” said Batterton, of the county Department of Human Services. Since then, she said, department staff has been “really diving into the gaps,” and now it’s ready to start filling them.
Gap 1: No alternative to 911
If you dial 911 and report an emergency, you should get “immediate” public safety service, according to the county. If you’d rather summon resolve’s social workers, you can dial the less-memorable 1-888-796-8226 (or 1-888-7-YOU-CAN).
That should change in mid-2022 when 988 service becomes fully operational nationally.
Pennsylvania’s Department of Human Services is drafting legislation on the funding and structure of the service in the commonwealth. A department spokesperson told PublicSource that the 988 line won’t just address suicide prevention.
“There could be fewer calls going to 911 and more calls going to 988, which we would envision as beneficial,” said Dalton. “We want less 911 calls. We want, more often, human services supporting people for things that are human services needs,” and 988 calls should trigger that kind of response.
Who will field the 988 calls? They could go directly to resolve, said Dalton, but that hasn’t been decided.
Gap 2: Rapid response to crises
Officials at resolve have long said that their teams of mobile crisis workers are usually dispatched to the scene of a crisis within half an hour of resolve’s switchboard receiving a call, but they’ve confirmed that it sometimes takes hours.
The county doesn’t intend to replace resolve. “I absolutely think that we’re in a good situation locally that we have a lot to build on,” said Dalton. “I can’t imagine a world in any short and medium term in which resolve isn’t part of the solution.”
“We hope to be involved with any of it and all of it that’s appropriate,” said Rozel. He added: “We don’t want to replicate or disrupt any of the really great services that are out there.”
Dalton’s department plans, in December, to invite other organizations — especially those led by Black and LGBTQ community members — to submit proposals for social work teams that would hurry to the scenes of behavioral crises.
Eventually, the county also wants to create a new, civilian-run system for transporting people who have been involuntarily committed for mental health treatment. Right now, police handle that. Batterton said she’s talked with officers who “don’t want to be cuffing people who are in behavioral health crisis.”
Gap 3: Alternatives to arrest
Local debate over police handling of incidents, especially involving Black residents, revived last month when a man died the day after Pittsburgh police shocked him with a Taser during an arrest in Bloomfield. Jim Rogers, who was Black, was accused of theft and failing to comply with police commands. Allegheny County police are investigating.
Pittsburgh police addressing incidents rooted in poverty, mental health or substance abuse now have the option of calling in a team of social workers staffed by the Allegheny Health Network [AHN]. Launched early this year, the AHN teams have responded to around 500 incidents, according to Dan Palka, administrative director of AHN’s Urban Health and Street Medicine program.
AHN’s work with the city resembles a decade-old concept called Law Enforcement-Assisted Diversion. LEAD encourages police officers to connect people in behavioral health crises to social service coordinators rather than arresting them.
The county is now working with the University of Pittsburgh’s Congress of Neighboring Communities, a coalition of the city and suburbs, to create a LEAD program outside of the city. By year’s end, Dalton’s department intends to seek proposals from vendors that would work with at least 13 suburbs, likely by sending case managers to supplement police at the scenes of behavioral crises.
Gap 4: A place to go, other than jail
The Allegheny County Jail and hospital emergency rooms are among the common gateways to mental health treatment. Dalton would like to create another option.
In December, the county plans to invite proposals to create one or two short-term residential “respite centers” for people with mental health or substance abuse problems who want to get help before a full-blown crisis puts them in the hospital or jail. At these centers, people could get support from peer counselors and referral to other resources.
This month, the county also plans to seek proposals from agencies that would provide housing for people with mental health problems who are leaving the jail.
Diversity and fair pay
Dalton said she’d like to see “a world where outcomes aren’t so disparate by race and other characteristics.”
Woven through the county’s plan are two concepts: involving Black-led and LGBTQ-led organizations in the emerging solutions, and paying the workers family-sustaining wages.
The county plans to insist that the agencies hired to fill the service gaps pay their workers $15 an hour or more. Dalton said human service workers are traditionally underpaid, and it is probably cheaper, in the long run, to improve their pay than it is to continually replace and retrain them. If initiatives like LEAD are to succeed, she added, the employees will need to develop relationships with members of the public and law enforcement.
County Executive Rich Fitzgerald has so far dedicated, for mental health services, $9 million of the county’s $380 million allocation of federal American Rescue Plan funds. Dalton also expects that Medicaid will cover some of the new services, and she hopes that private insurers will “be chipping in.”
Long-term, such investments will pay off, she predicted.
“I do envision a smaller jail,” she said. “If there are fewer people ending up arrested and jailed for nine months awaiting trial on something, there will be returns and resources to the community.”
This story was fact-checked by Amelia Winger.
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