nh · rfi question responses ... to requests for evaluation of crisis regardless of where the...

NH DHHS STATEWIDE MOBILE CRISIS RESPONSE TEAMS

TABLE OF CONTENTS

Transmittal Cover Letter ....................................................................................... 1 Table of Contents .................................................................................................. 2 Executive Summary ............................................................................................... 3 RFI Question Responses

Question One ............................................................................................ 5

Question Two ............................................................................................ 6

Question Three ........................................................................................ 11

Question Four .......................................................................................... 14

Question Five ........................................................................................... 16

Question Six ............................................................................................. 17

Question Seven........................................................................................ 19

Question Eight ......................................................................................... 20

Question Nine .......................................................................................... 21

Question Ten ........................................................................................... 23

Question Eleven ...................................................................................... 24

Question Twelve ...................................................................................... 25

Question Thirteen.................................................................................... 27

Question Fourteen .................................................................................. 29

Question Fifteen ...................................................................................... 30

Question Sixteen ..................................................................................... 31

Question Seventeen ................................................................................ 32

Question Eighteen ................................................................................... 33 Budget ................................................................................................................ 34 Budget Narrative ................................................................................................. 35

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EXECUTIVE SUMMARY:

The NH Community Behavioral Health Association (CBHA) is an organization comprised of the ten community mental health centers (CMHC) throughout New Hampshire. These centers serve individuals in our state who are living with – and recovering from – mental illness and emotional disorders. This network of mental health centers provides emergency and ongoing behavioral health services to New Hampshire residents, both children and adults. CBHA is responding to the State’s recent RFI‐2020‐DBH‐01‐Mobil for Statewide Mobile Crisis Response Teams. CBHA and its members are key components of the behavioral health system that has a long history of meeting the needs of people in crisis across the State. This Request for Information (RFI) will set out ideas for a system that allows for consistency of clinical intervention and the flexibility of providers to meet the very specific needs of the geography and demographics of each region. It is essential that this model have a centralized locus of control, a role that will be executed by the CBHA and a group of clinical providers who are aware of their own regions and familiar with the issues, challenges and the solutions that will meet the needs of the people of those specific locations. By providing a central locus, there will be oversight and quality measures to ensure that each person reaching out to a MC Team will receive services based on best practice for the situation. This RFI response envisages a collaboration of clinical providers playing a role of covering the state with clinicians, case managers and peer support specialists who will respond in real time to requests for evaluation of crisis regardless of where the person is or the presentation and acuity of the issue that presents. This system will be responsive and thoughtful as to disposition and will evaluate at triage the most effective place for evaluation and in turn the most appropriate disposition with a goal of matching services with need. All interventions are predicated on the least intrusive disposition necessary that always aims to maintain community tenure with a strong and timely referral for outpatient support for those in need. This system design anticipates the potential challenges of geography, consistency of clinical intervention, staff and workforce issues and access to resources. At the same time the RFI considers the benefits to a system which supports people remaining in their communities, including children, elders and special populations such as the LGBTQ population, the dually diagnosed, and people with developmental disabilities. The collaboration that this RFI suggests is one that is forged from many years of engagement and work on common goals from members of the CBHA. The group is the best qualified to address the issues of workforce, best practice clinical intervention, and network of coverage. The model suggested is one that is managed administratively by the CBHA and clinically

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executed by its members. It is a model that is efficient in that it builds on existing services and is best suited to meet that challenges across the continuum of rural, urban and suburban New Hampshire. Further it is a model that already has a clinical infrastructure, significant experience in best practice intervention and a reputation that can support this new venture.

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Q1. Briefly describe your organization, who you serve, and any experience/expertise specific to behavioral health crisis response services.

The NH Community Behavioral Health Association (CBHA) is an organization comprised of the ten community mental health centers (CMHC) throughout New Hampshire. These centers serve individuals in our state who are living with – and recovering from – mental illness and emotional disorders. This network of mental health centers provides ongoing and emergency behavioral health services to New Hampshire residents, both children and adults. The goal of the Association is to raise awareness about the crucial role played by community‐based mental health centers to ensure public safety and overall public health for all New Hampshire residents. In addition, the Association serves as an advocate for a strong mental health system across New Hampshire. Two of the association members are the providers for Mobile Crisis Teams (MCT) in New Hampshire. Concord was the first MCT in 2015 and Manchester the second in 2017. A third MCT is operational in Nashua. These teams are fully functioning and provide 24 hour coverage for community based crisis evaluations in their regions and each have 4 crisis apartment beds that serve as diversionary destinations from inpatient psychiatric care and from Emergency Departments. Riverbend also has a Behavioral Health Crisis Treatment Center, an urgent care behavioral health walk in center that has been operational since May, 2019. The remaining eight CMHCs all provide emergency services to the majority of the 26 acute care hospital emergency departments in the Granite State.

CBHA has a long history of coordinating efforts that create statewide solutions to mental health issues such as the CBHA initiative which managed data and analytics for the State and the recent workforce project that was able to raise awareness statewide around the issue of vacancies in the behavioral health system.

CBHA’s membership is far wider than the CEO membership. It is able to reach into its member organizations to access the expertise of its workforce and it is felt that this depth of talent will be a good resource for conceptualization and operationalization of the newly proposed state wide mobile crisis model.

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Q2. Describe any experience/expertise or lessons learned operating mobile crisis response services and/or statewide integrated teams specific to the factors to consider listed in Section 4. Clinical need: The process of acute clinical risk assessments and individualized diagnostic and treatment formulations for presenting clients should begin ideally within one hour of the client’s clinical readiness for the behavioral health interview but in more remote areas of the state more time may be necessary. Crisis assessments include: presenting problems and a narrative of how and why the client is presenting at this time; immediate safety concerns from the points of view of the client and, when possible, referring parties and other collateral sources; crisis precipitants including potential primary and secondary gain; internal and external supports; history of relevant past symptoms; safety concerns; past presentations, treatments, and treatment reediness; medical and substance co‐morbidities; functional status; relevant legal issues; current mental status exam with serial assessment over time and in response to immediate treatment interventions. The clinical evaluation will be based on an agreed upon standardized risk assessment such as The Columbia Suicide Severity Assessment Screening tool and level of care determination will always be based upon medical necessity and with a balance of lethality and maintaining community tenure. Staffing: The workforce shortage in NH has impacted service delivery directly and indirectly. A 24/7 program that requires heavy staffing patterns with surge capacity is challenging in an environment where positions are open for prolonged periods of time. The indirect impacts are significant yet less obvious and visible to those outside of operations. Some of our major findings include the following areas of concern and opportunity:

Capacity: Issues with a depleted workforce have led to the reliance upon per diem staffing to cover holes in schedules. Many of the per diem staff work full time in other departments and other agencies and some work sporadically. While this has been effective for continuing basic operations, the number of staff working in our Emergency Services departments has ballooned. This creates challenges with supervision and communication and has resulted in an increased reliance upon written communication which is far less effective that in person staff meetings where the synergy of discussion provides opportunities for learning. These less effective systems of communication may create inefficiencies as managers’ work to correct course.

Supervision: All responsible and effective clinical services must have competent and accessible supervision. Mobile Crisis Teams (MCT) will need to have on‐site and/or on‐call supervision available to them for complicated cases and cases involving the need for higher level risk management beyond the safety assessment. Issues with capacity tend to amplify the need for supervision including the need to debrief difficult phone calls.

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In addition, as a result of a depleted workforce, supervisors are sometimes required to provide coverage for clinical positions which adversely affects their availability and responsiveness to requests for consultation.

Triage: The initial point of contact has shown itself to be the most important step in the MCT workflow. Effective and efficient triage prior to the dispatch of any team is essential for the management of risk and resource.

Cultural needs of people in crisis and their families: Any contract offered by the State should be mindful of the cultural needs of all of the populations that are served. New Hampshire is indeed a diverse population and a Request for Proposals should expect that there is some basis for ensuring that crisis services are meeting the cultural needs of the people served. A requirement that there be a framework for educating the workforce around cultural issues such as Appreciative Inquiry should be noted. Client Experience: While it is easy to understand how Mobile Crisis services are preferable to Emergency Services which are delivered primarily through emergency rooms, there are some aspects of the current design that bear consideration for any efforts aimed at improving the overall client experience of MCT:

Peers: Peers have proven to be a valuable component of the overall delivery of crisis services in NH. Clients benefit from a firsthand account of recovery and the joint venture of clinical services paired with peer services strikes a valuable cord. Managing a team of peers in the absence of a statewide infrastructure that promotes consistency of practice and role expectations creates variability in service delivery. The State would benefit from the establishment of clear guidelines for peer certification to include best practices for hiring and supervising peers with well‐defined roles for MCT teams. These guidelines need to be paired with consistent, frequent, and affordable training for peers and for those providing supervision to peers to maximize effectiveness.

Contingencies in Schools: There are some situations when a child is taken out of school for behavioral/psychiatric reasons and is not allowed to continue his/her education until s/he is seen by a mental health provider. MCT may not be the appropriate service in these situations, however the guideline around these practices are not clear and it is difficult to understand where the authority lies in these situations. Providers of crisis services would benefit from clarity about these issues.

Mobile Interpreter Services: In order for MCT to service the population in its entirety we must remove language barriers with the use of mobile technology.

Crisis Apartments: Existing MCTs have found that the respite crisis apartments are an extremely important component of the overall delivery of services. Considered a

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preferred alternative to psychiatric hospitalization, crisis apartment admissions allow for stabilization of a psychiatric crisis. There are times when there are clinically appropriate reasons to extend an admission beyond the current 7‐day limit and flexibility in this area is important. The absence of apartments would undoubtedly result in more psychiatric hospitalizations and higher utilization of emergency rooms.

Approaches and tools used for different populations: While attention should be paid to the needs of different populations, a consistency of tools used should be a priority for this project to ensure a consistency and quality of services delivered throughout the state. It is imperative that clinicians are using tools that are approved as best practice interventions with people in crisis. An example of this is the Columbia Suicide Severity Rating Screening tool which is currently used by the state’s Community Mental Health Centers and the hospitals in the NH Hospital Association. This has led to better consistency of evaluation and a higher likelihood of getting the same quality of service across the system. There should be attention paid to a distinction between interventions for children and those for adolescents and adults. Interface: Partnerships with other community services are extremely important to the success of this state wide project. Communication about the goals of Mobile Crisis interventions, its use and the range of services needs to be communicated well in order to avoid frustration and wasted resources. Therefore, adding resources within MCT dedicated to liaise with all community stakeholders should be considered.

Law Enforcement/First Responders: A large percentage of referrals to MCT services are from police and EMS. Issues such as medical clearance, appropriateness for drop off versus requesting a mobile assessment as well as issues of client & staff safety are all important to the efficiency of the system. Mobile crisis teams with the closest collaboration are effective in educating the police regarding basic mental health first aid including verbal de‐escalation, and recognizing signs of mental illness. Towns that have small police departments with high turnover present added challenges and therefore liaisons with all departments for ongoing communication are needed.

Schools: Some schools seem to be less able to manage behavioral health issues than others. There are instances in which schools inappropriately request mobile crisis services for minor behavioral difficulties which results in the unnecessary use of this limited resource. Education and consultation with the schools will support the appropriate use of the mobile crisis services in that venue.

Hospitals and other mental health providers: In a general way, hospitals and behavioral health providers outside of the community mental health centers provide referrals but

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also are involved in dispositions of crisis calls. Communication and reciprocal understandings of operations are paramount.

Approaches and ideas regarding the provision of service in a community‐based setting rather than in a person’s home and continuum of emergency services, including existing emergency services and mobile crisis delivery system: As an example, in Concord as the continuum of services has grown over the past 4 years there has been an emphasis on creating administrative steps that ensure that decisions around the location of evaluations are made with the default that an evaluation will take place in the community. An example of this is that all calls go through a single triage number that is now well known in the community. Staff triaging begins with a conversation about how a crisis evaluation can take place safely in the community. If it is not possible due to client choice or previous concerns over safety, the triage clinician discusses the possibility of the client coming into the Behavioral Health Crisis Treatment Center and only when this community based option is not possible, a decision is made to arrange an evaluation in the secure surrounding of the hospital emergency department. This process is backed up with administrative requirements by policy and procedure. If a community based evaluation is not possible as determined by the triage clinician then this triggers a determination by the Administrator on Call who has to approve a client being seen in the Behavioral Health Crisis Treatment Center or in the ED. Mobile Crisis teams that exist currently have the requirement that master’s level clinicians will go into the community with a Peer Support Specialist and this team approach to psychiatric crisis work has ensured that the majority of evaluations that are performed are in the community. Funding, with an emphasis on maximizing private and public insurance participation: From the perspective of the two mental health center mobile crisis teams who are members of the Community Behavioral Health Association, the experience related to funding of the teams has been a difficult one. There has been an expectation that after general funds, the programs would be able to bill to third party payors to make up the shortfall in funding to keep a program such as this open 24 hours a day with the full array of services needed for each team to answer calls and send staff into the community within one hour to begin the assessment. If there is an expectation that the service is statewide, it cannot merely function as a general fund Medicaid billing line of business. This has been demonstrated by the annual losses incurred by two MCT teams. It is strongly suggested that private insurance companies pay for the service. Often they will deny payment or refuse to contract for the service or simply ignore requests for payment. Local teams should be able to negotiate contracts for mobile services and ideally have the Department of Insurance require that they contract for these services if they want to do business in the State of New Hampshire. Workforce and staffing needs, for example, staff competencies, areas of expertise, and specialty training requirements: See Question 15

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Hours of operation: Mobile Crisis services should be a 24 hour program that is exquisitely linked with local services such as Emergency Services provided by CMHC’s and Hospital ED’s. Centralized triage services would be staffed 24 hours a day by trained emergency psychiatric service clinicians with peer support for warm line calls. Centralized triage services will have memoranda of understanding with local mobile teams and they will respond 24 hours a day to requests for clinical intervention in the community. It is important that the local teams are given flexibility around the way in which they cover services. This flexibility will allow more rural areas to design coverage maps that are achievable given small populations spread over large geographic areas. Local hospitals will act as back up for times when a mobile evaluation is not possible. Technology infrastructure needs: As with all community based mental health and substance use disorder services, mobile teams will need the most advanced ‘field’ technology. Examples of this would be ‘Thin Client’ type computers that allow employees to document their work in real time and have it available to colleagues back at the offices. These units hold no information on local drives, thus are safe if lost or stolen. The new statewide system will also need to make use of the newest and most secure systems for tele‐health. There are examples of this already in effect in some ED’s around the State, including at Dartmouth Hitchcock. Technology will be a large piece of this project and an example of flexible funding for HIT is the way in which the Integrated Delivery Networks were able to use monies to purchase data sharing and analytics platforms to enhance the quality of communications between them. This concept should be explored for a statewide mobile crisis project.

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Q3. Provide your recommended approach for the provision of statewide mobile crisis response services. Specifically how will the recommended model enhance, augment, strengthen, and/or expand existing resources? The Community Behavioral Health Association’s (CBHA) proposal for state wide Mobile Crisis Teams (MCT) is predicated on the notion that the ten Community Mental Health Centers (CMHC) are already a network of agencies that provide comprehensive behavioral health community based services. The array of interventions available span outpatient therapy, service for people with serious and persistent mental illness, residential care, substance use disorder treatment, day treatment and emergency services in neighboring hospitals. Members of the group also provide integrated care in primary care settings and reverse integration programming in some settings. These agencies recently celebrated their 50th anniversaries as community based mental health providers and this long history, excellent relationships in their communities and the broad array of services provide a robust foundation for statewide coverage of mobile crisis services. The existing infrastructure is already serving adults, children, elders, people who struggle with addiction and many specialty groups such as LGBTQ population, people with co‐occurring issues such as mental health and addiction or mental health and developmental disabilities and many other specialty populations. This is a foundation for a mobile crisis response that is not replicated elsewhere in the State. The CBHA works on behalf of the ten community mental health centers to negotiate contracts with the managed care companies and has expertise in providing data support, analysis of issues that affect the workforce and strong advocacy on issues related to people with mental illness with state and federal branches of government. As noted, the CBHA has a depth of resources beyond its CEO membership and it often brings together specialty groups to address specific common issues. An example of this is the executive director workgroup originally led by one of the CEO’s and staffed by the Emergency Services directors. This group developed a set of recommendations around clinical tools and interventions that are now in place at all hospitals in the state relative to consistent suicide risk assessment. The recommended approach for this state wide model is to form a group of all of the CMHCs organized through the CBHA. Each represented CMHC would have responsibility for 24 hour mobile crisis coverage and the accompanying services that are requested in the response to the RFP. It is very important that all CMHC’s have a good amount of flexibility in how they cover different parts of the state especially the northern area of 3,590 square miles with a population of only 125,432. More traditional coverage in this rural area would not be possible and local

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solutions must be viewed as essential for areas such as this. On the question of crisis apartments, while these are extremely useful it might not be possible to make such a resource viable in large rural areas, yet the provider in such area might be able to make arrangements with existing residential providers to rent beds for use as a diversion from higher levels of care. Again, the state should support flexibility in care solutions and recognize that each region has its unique needs and resources. While CMHCs will plan their own local interventions relative to clinical evaluation which meets the requirements of the RFP, initial triage would be managed through the Association (CBHA). It is proposed that CBHA would manage the entire contract and then sub contract with the ten CMHCs to provide the local programs. The CBHA would manage calls as they come into a centralized number and those Master’s level clinicians would assess for lethality, determine the level of intervention that is clinically necessary and then transfer the call to the appropriate mobile crisis team. It should be noted that this centralized, easy to remember number will become the crisis line that is the correct number under any circumstance. Clinicians will manage all calls and get individuals to where they need to be regardless of what that need is through a process of warm handoffs and closed loop referrals. The triage line will develop relationships over time with providers of care in other disciplines such as VNA, EMS, and providers who manage the social determinants of health. The triage line will be staffed 24/7 by clinicians either employed by the CBHA or ‘hired’ from the ten CMHC existing staff. The clinical work should be consistent in each area of the state and assessment tools used will be consistent across triage and the community based work. Clinical oversight of the state wide program will be the responsibility of the Association which will ensure the consistency of interventions. Triage clinicians would also be able to utilize peer support specialists who would staff a warm line for individuals who need to talk but who are not in an identified crisis. An alternate model might be to build upon the existing infrastructure for 211. In this way, 211 can serve as the initial access point for the entire State. Resources devoted to 211 may allow for expansion of some initial screening questions that would then improve support for warm hand‐offs to the local MCT triage clinicians. In this model, the clinical triage would remain with the local MCT teams who would then be in the best position to mobilize local resources that would include nuances to specific areas of the state. 211 staff would be able to do initial screening to eliminate non‐crisis calls from getting through to local crisis lines & would afford the possibility of providing referrals for non‐emergent needs that were expressed during the call. Support and consultation for the 211 staff could be provided by the CBHA whereas the management and supervision of the local MCT teams would reside with the center in a given region. In both models, the administrative oversight and responsibility for ensuring consistency

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and quality of services throughout the state would lie with CBHA with administrative staff that are hired for this statewide program. Peer Support Specialists should be a significant part of the programming in this model. Peers will be available at all points of the clinical intervention; at triage, evaluation and post crisis intervention. The CMHC’s have invested heavily in people with lived experience and those resources will be channeled into the statewide service. Intentional Peer Support and Certified Recovery Support Worker certification is a part of MH and SUD peer qualification in the CMHC agencies and these certifications allow for educated use of life experience and consistency of intervention. Programming for mobile crisis that is statewide and organized by the CBHA would be able to integrate two of the existing mobile services into the new programming. Expertise in running these programs in Concord and Manchester will be essential in planning the statewide rollout. To provide for consistency and full integration of MCT services into the unique continuum of care that CMHCs provide, we would recommend that the current MCT contract for Nashua be transferred to the local CMHC in Nashua.

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Q4. Provide a description of the array of services that could be delivered through your recommended model, including by sub populations (adults, children, mental health, substance use disorder, co‐occurring disorders) and if services focus on the immediate behavioral health crisis or address more broad social determinants of health MCT will serve all persons ‐ children to older adults including vulnerable populations: minorities, persons with limited English proficiency (LEP) and persons of the LGBTQI community. The focus of services is the behavioral health crisis presentation and the provision of clinical intervention/ triage to determine: 1) risk to self or others 2) precipitants to the crisis situation 3) drivers that will sustain or diminish the intensity of the crisis including social determinate factors: financial, food security, housing, social inclusion/ supports & employment. Specific services to be provided are:

Phone Triage: The phone call will be the initial contact with a person in crisis. A Master’s level clinician will answer incoming calls. This clinician will complete the initial risk assessment and score the assessment to support making a determination as to what level of service will be provided to the caller. It should be noted that telephone triage will also be utilized for information and referral to the community, and to assist the caller by providing information to make informed decisions about accessing services related to their identified crisis.

Phone Support: The person will be provided with supportive listening, problem solving, coping skills utilization and referrals by a Master’s level clinician, and/or a certified peer specialist.

Lethality Assessment: An intensive, face to face assessment will be completed by a Master’s level clinician that includes a direct interview of the person in crisis. The interview will include taking a history, conducting a mental status exam and psychosocial assessment inclusive of input from others as indicated, an analysis of risk versus protective factors, a determination of level of risk for self‐harm and harm toward others, diagnostics, and the creation of a disposition/crisis plan. This assessment is viewed an as intervention in itself because the clinician will use skills to ameliorate discomfort and affirm the client’s crisis, and further to identify and activate the person’s own skills to manage the crisis. The assessment is not merely a judgment of risk and level of care to manage risk. It is also an intervention designed to inventory, encourage development, and implement the person’s own crisis management skills and instill and reinforce a sense of empowerment, respect, self‐determination and partnership in his/her steps towards optimal resolution of the crisis.

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ASAM: The clinician will gather information and perform an assessment, to include American Society of Addiction Medicine (ASAM) criteria, to determine the extent to which substance use impacts the disposition. The ASAM scale will help to gather preliminary information that can be used to create a plan to address the level of care indicated. In many instances a connection to the State Doorway system would be indicated.

Peer Specialist Support: Peer specialists have specialized training in addition to lived experience. The peer specialists will offer specialized, recovery promoting activities. Along with those, they will provide supportive counseling that potentially normalizes the person in crisis’ experience, leads to decreased anxiety through supportive listening, identifies potential community based resources, and assists the person seeking help with practical problem solving around life stressors. Services will be provided in a synergistic fashion with a strong partnership between all members of the team including clinicians, psychiatrist/ARNP, peer specialists and crisis case managers.

Crisis Stabilization: A Master’s level clinician will provide ongoing lethality assessment and therapeutic services until a client is connected to a community based service that will support him/her in a return to the pre‐crisis level of functioning. Assessment and therapeutic services are based on best practices and evidence informed approaches.

Crisis Case Management: Supportive counseling will be combined with expedited and affirmative linking with community based services. This service builds upon an already mature agency’s set of community linkages and deep knowledge of community supports and resources as well as knowledge about how to access them. It is suggested that the statewide MCT response model includes staffing for a case manager whose role would be to assess and refer to appropriate services to support the person’s return to their previous level of functioning.

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Q5. Describe the expected ratio of services in this model of face‐to‐face versus phone or in office contacts.

While it is difficult to estimate what the ratio of services will be in a state wide model, information from two MCT programs was gathered to support this prediction. It is expected that 1 out of every 3 calls will result in an assessment and that between 60% and 80% of the assessments will occur in the community rather than in an office.

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Q6. Provide a description of how this model will successfully deploy mobile crisis services in both densely populated and rural regions within a designated timeframe, such as one hour.

Rural Areas

Suicide rates are generally higher in rural than in urban areas. Rural northern NH areas can present challenges for suicide prevention. Homes are often more spread out and access to health and behavioral health care providers and emergency medical facilities are more limited. Access to lethal means, particularly firearms, is also greater in rural than in urban areas. Strategies to consider as a part of a comprehensive approach to a statewide mobile crisis response are the use of tele psychiatry and mobile crisis teams to support individuals at risk.

Upon receiving a call, mobile crisis clinicians will ask a series of questions to determine the most clinically appropriate response. Information from the central triage service will also be used to inform this assessment. The person calling may be provided information for outpatient services, be directed to the nearest mental health center, the emergency room or 911 might be dispatched, depending on the circumstances of the call. A face to face assessment may not be conducted if the person’s condition is sufficiently stable to seek non‐emergent behavioral health care. In all other circumstances, a Mobile Crisis team would be dispatched.

A face to face response will occur within 2 hours of receipt of the call requesting assistance. The response time will not exceed 4 hours.

Some flexibility will be necessary to account for circumstances beyond the control of the MCT ‐ for example, inclement weather, call volume that exceeds the capability of staff on duty, etc.

Mobile crisis staff will be led by Master’s level clinicians who are able to see individuals in crisis in a variety of settings. The goal is to provide comprehensive assessments to assure that each person receives the appropriate level of care. When appropriate, staff may see clients via telehealth services to decrease the time to assessment. When conducting assessments in non‐ public settings such as a client’s home, the clinician will be accompanied by a case manager or peer.

For a mobile crisis response team in the North Country, a minimum of three (3) discrete teams are needed to cover the geographical expanse of the region. The region is 155 miles from north to south and 100 miles from east to west. Berlin, Littleton and Conway are the recommended hubs for each team. The minimum required staff composition for each team for each of three shifts is one clinician and one peer. During regular business hours during the week, a case manager will also be employed. To assure 24/7 access to psychiatric consultation, an APRN would need to be added to the staff composition and would cover all MCT teams.

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It may be appropriate to consider the possibility of subcontracting with private practice master’s level clinicians to provide the MCT coverage in some areas of the region. Over time, it may be a more effective and timely response to specific remote areas in the Northern region. The specific expectations, including areas of competency and team compositions, would be the same as for any mental health center staff who provides MCT services.

Urban areas:

Initial phone calls to the Mobile Crisis team will be answered by a Master’s level clinician who will ask questions to determine the most clinically appropriate response. Information from the central triage clinician will be part of this evaluation. The options for response include the following considerations:

Whether the person’s needs may be met telephonically‐ providing support over the phone or by giving needed information.

Whether face to face assessment and intervention are needed,

Where and when the assessment and intervention can safely occur, with immediate response in the person’s natural environment being the default choice.

Whether there is a need to request police to accompany the staff to the assessment

MCT clinical staff will respond to a need for crisis assessment and intervention within one hour of receiving the call. The natural environment will be defined as the person’s home, other residences (for example, the homes of supportive relatives), community settings including homeless camps and outpatient settings (PCP offices, city welfare and other social service agencies, therapist offices, etc.), or police stations. Every effort will be made to assess and intervene in the person’s natural environment. When conducting assessments in non‐ public settings such as a client’s home, the clinician will be accompanied by a case manager or peer.

Crisis assessments will be performed by Master’s level clinicians with the support of peer specialists. During regular business hours, a case manager will be employed to support client’s community based needs. Leadership at the administrative office will provide oversight. In addition, on‐call administrative support and consultation should be available 24/7 at each CMHC.

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Q7. Describe how this model will utilize best practices to meet the needs of currently underserved population including people who identify as lesbian, gay, bisexual, transgender, questioning (LGTBQ): transitional age youth and young adults; pregnant women with BH conditions; and racial ethnic and linguistic minorities.

It is essential that a state mobile crisis response system ensure access for underserved populations. There are multiple levels at which programming can be put into place to assure this. As with all behavioral and health services, translation and interpreting services must be available, whether in a rural or urban part of the state. It is recommended that staff have CLAS training to ensure cultural and linguistic competence. In order to increase accessibility for lesbian, gay, bisexual, transgender, questioning (LGTBQ) people, providers must be trained in regard to supporting self‐identification of gender and pronoun use. Information about resources and supports for people struggling with issues related to self‐ identity should be readily available to staff of each Mobile Crisis Team (MCT). In order to address the needs of transitional age youth, each MCT program will need staff trained, or available consultation from both the adult and child world. This includes access to people with significant knowledge about the primary systems in which transitional age clients engage, such as school, special education, vocational programs, and juvenile justice, adolescent substance use treatment, child protective services, and developmental services. The MCT program should include a peer component, and it is recommended that efforts are made to include a wide range of peers, including young adults, people who identify as LGTBQ and various cultural minorities at the local level.

In order to meet the needs of LGTBQ individuals, MCT staff should not impose a binary view of gender and should convey acceptance of a wide range of gender expression. MCT clinicians and peers should have basic competencies in understanding gender identity and language. Training for staff should include an understanding of how societal attitudes towards LGBTQ populations impact mental health. Subsequently, there should be a basic understanding of how people’s comfort in sharing experiences vary and will impact assessment and engagement/rapport. Clinicians should be competent in the use of DSM 5, with specific focus and understanding in diagnosis of gender dysphoria and differential diagnostic considerations.

Specific training of LGBTQ related domestic violence issues, de‐pathologization of non‐hetero, non‐cisgender, non‐monogamous sexualities and relationships will be helpful for staff providing MCT services in all parts of the state.

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Q8. Include a description of any efficiencies that may be gained through the model. Any statewide initiative will carry a relatively high cost of operation due to the diversity of areas and the fact that there are differences in population and geography. A mobile crisis program in the end is a labor intensive and relational process. There must be regional clinicians providing services that are informed relative to the distinctions and divergences of each corner of the State. However this model does allow for efficiencies in that there will be one single point of contact for all people in the state to call. The service will be in support of all of the local teams who are providing services at the point of care. This negates the need for local triage points of contact and allows the screening and triage to happen centrally. This will also create consistency of clinical evaluation and services and will ensure that staff at local destinations is utilized to their maximum potential. All ten Community Mental Health Centers (CMHC) will be a part of the network and all 10 CMHCs are members of the Community Behavioral Health Association (CBHA). There is a built in efficiency of leadership and authority in this plan. The CMHCs already have a trusting and close relationship as witnessed by negotiating contracts and planning for other statewide initiatives. This relationship will be effective in managing coverage issues. As staffing models are built they will not take into account the possible surge in demand. Assistance in meeting that demand will come from sharing staff across regions. The consistencies of clinical intervention that will have been built in will allow clinicians to be flexible to support coverage systems. The CBHA will work with all insurance carriers to contract for this level of care. This central point of contact with insurers will help generate revenue to offset the state’s cost for this service. CBHA would also work in a ‘Messenger’ model with existing Medicaid managed care entities which will create efficiencies for contracting departments.

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Q9. What other relationship/partnerships would support the implementation of this model? Include a description of both the role partners would play in program implementation/operations and financial sustainability. Relationships with the following organizations will be important for each regional Mobile Crisis

Team (MCT) to explore:

First responders

Hospitals

Police departments

Colleges

Veteran resources

Refugee organizations and providers of services to newcomers

Private therapists’ offices

Primary care Offices

Consumer/Peer support programs

Homeless resources.

City welfare offices

Family health centers

Mental Health Courts

Partnerships with first responders will provide both a referral source and a measure of safety. Community medical providers, schools, Doorways, the safe station, homeless shelters, hospital emergency departments, and other community providers will provide referrals, resources, and public support of the MCT model.

Law Enforcement/First Responders: A percentage of referrals to MCT for services are from police and EMS. Issues such as medical clearance, appropriateness for drop off versus requesting a mobile assessment as well as issues of client & staff safety are all important to the efficiency of the system. Mobile crisis teams with the closest collaboration are effective in educating the police regarding basic mental health first aid including verbal de‐escalation, and recognizing signs of mental illness. In some regions, Crisis Prevention and Intervention (CPI) training for police departments could be provided by mobile crisis staff. Towns that have small police departments with high turnover present added challenges and therefore liaisons with all departments for ongoing communication are needed.

Schools: Education and consultation with the schools will support the appropriate use of mobile crisis services in that venue. There are instances in which schools inappropriately request mobile crisis services for minor behavioral difficulties which results in the unnecessary use of this limited resource. These situations would be

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opportunities to educate schools about how to best utilize the mobile crisis services for their specific population.

Hospitals and other mental health providers: Hospitals and behavioral health providers outside of the community mental health centers provide referrals and can but also be involved in the dispositions of crisis calls. Communication and reciprocal understandings of operations are paramount in order to ensure continuity of care for clients.

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Q10. Provide an overview of the technology and infrastructure needed to support this model. State level: A state wide model with a triage function would require a 24/7 centralized toll free phone number. This phone system which will be at the central location where triage services are provided should have hunt group capacity so that multiple calls can come in at the same time and be answered live. There are phone systems that gather and hold information similar to that used by the 211 statewide systems. It is suggested that the state support the efficiency and effectiveness of this model by encouraged the use of sophisticated systems that will support call transfer as well as call data collection At the state level, there must be computer programming that supports quality and data reporting with information from the triage line integrated with information from the mental health center interventions at a micro and macro level. As field staff may not be in a central location, there must be advanced phone technology so that transfers from the central triage clinician to the mental health center staff happen seamlessly. Local level: The mental health center locations should incorporate both landline and cellular phones to provide the most versatility for clinicians providing mobile assessments. Ideally the computer technology would support both inter agency and intra agency transfers (i.e. transfer to/from emergency responders and social service agencies). The system should have remote hunt group capacity to move from one phone to the next if the initial Mobile Crisis Team line is busy. In addition there should be technology to support interpretation services. In order to ensure mobile assessments and coordination of care, computers/laptops/tablets should have programs that provide access to electronic medical records of the respective mental health center.

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Q11. Provide a description of step‐wise options to implement the proposed model(s) including specifics regarding hours of operation and provision of services to all geographic regions.

No answer

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Q12. Provide details on the required team composition needed to deliver the scope of services proposed in your model, including staff competencies, areas of expertise and specialty training requirements.

o Mobile Crisis Team should include a Master’s level clinician paired with a trained Intentional Peer Support trained person with lived experience and a bachelor’s level case manager.

o The triage staff should have a Master’s level clinician who answers the phones. In addition the triage office should have trained peers who can provide phone support to callers whose primary need is telephonic support.

o Staff competencies for the clinicians should include at a minimum, training in the following:

o Lethality and Risk assessment o Mental Status Exam o Columbia Screening tool o IEA procedure including exclusionary criteria o Substance Use assessment – ASAM as an example o Trauma informed care o Violence Risk Assessment o Extensive knowledge of DSM 5 including agitated delirium, post‐ partum

psychosis o Knowledge of resources in area for SUD, LGBTQ, New Americans, domestic

violence, developmental disabilities and elder supports o Knowledge of hospital based services such as MAT induction in EDs, urine

screening for SUD etc. o Children specific competencies

Consent/Guardianship/Legal Issues Abuse and neglect reporting Child serving community systems (School, DCYF, Child Care, Medical,

legal, other) Children’s Mental Health status exam/clinical presentations in children,

(including trauma response) ACES/understand impacts of trauma on development, long and short

term Assessing parental capacity to maintain safety Crisis response/de‐escalation for children

o Each mobile crisis team should include peers who are trained in Intentional Peer Support and IMR.

o In addition, each mobile crisis team should include a case manager who will work Monday through Friday during regular business hours. They will have a bachelor’s

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degree in a human service field with at least a year of experience in working in behavioral health. Staff competencies should include at a minimum:

Certified in ANSA or competent in DLA 20 Motivational interviewing Stages of change Understanding of community resources Client centered treatment planning Understanding of the NH Medicaid application process

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Q13. Describe any challenges that need to be considered under this model.

Geography: New Hampshire is a diverse geographic area with pockets of urban population and also large tracts of rural topology. An example of this is in Northern New Hampshire the smallest population, 125,000 people are spread over 3,590 square miles. By stark contract Manchester stretches over 35 square miles and its denizens are 110,000 strong. Urban areas pose different issues to rural ones. There are issues of safety for mobile staff working in the community in both areas. Issues of transportation and the ability of clinicians to cover vast geography in rural areas will have a detrimental effect on the requirement for a one hour response time. Less traditional staffing methods such as contracted clinicians who work from home and telehealth solutions must be explored in these rural areas. Socio‐economic Disparities: Implementing a statewide program means that there is also a great disparity in socio economic opportunity. Pockets of poverty exist amidst area of great accumulated wealth and there are many ‘hidden poor’ populations who are hard to reach and may be challenging to connect to resources. Consistency of Clinical Intervention: It will be a challenge to develop a consistent clinical model of intervention across 10 entities with such diverse backdrops to the essential work that needs to be done. Having a centralized administrative office with clinical oversight will support consistency of services across the state. Flexibility is a must when DHHS writes any RFP that hopes to cover New Hampshire in a way that makes clinical and economic sense to providers. In this model it would be the Community Behavioral Health Association that would be responsible for quality and consistency of intervention, informed by best practices. Economics and Workforce: The State of New Hampshire has a history of chronically underfunding human service programs. The Community Mental Health Centers (CMHCs) have struggled for the last decade with no rate increases and new programming that does not cover costs. Agencies are left to fund raise to make up the difference and this has a detrimental impact on quality of programming as oftentimes agencies lose staff to settings that can afford to pay staff up to 50% more than the CMHCs are paying. This can cause high turnover and large expense incurred by agencies when they hire and train new staff. Health care in this state is at negative unemployment as there are over 2500 vacancies in the system. The CMHCs are carrying 250 vacancies at the end of 2019 and the majority of those are clinical positions. There is a lack of qualified clinical staff to fill these positions and creating a large statewide mobile crisis program will probably serve to pull qualified candidates away from existing services or retain a sizable vacancy rate over a period of time which will make it very hard to cover all shifts and provide a program that is 24/7.

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Scope of Training: Putting together a team of clinicians and peers who require a large scope of specialized knowledge will be a challenge. As the system requires 24 hour coverage the program will require three times the amount of staff that would cover a regular day time program and recruiting, training and retaining that group will likely be the biggest challenge of all. Ideally, staff will be hired and trained prior to the implementation of this statewide program.

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Q14. Describe any required data collection measures needed to address the effectiveness of these services. In order to analyze the effectiveness of the services of a statewide mobile crisis response program, the following information would be needed from each mobile crisis team:

‐ Number of unduplicated people served by phone and in person assessment ‐ Office versus community assessment ratios ‐ Number of people who were seen within an hour of the call or time from call to

assessment ‐ Client age ‐ Time of call ‐ Services provided by type

o Phone triage o Mobile community assessments o Office based assessments o Crisis stabilization services o Case management o Phone support alone

‐ Referral Source ‐ Diagnosis of client ‐ Number of people requiring interpreters ‐ Number of hospital diversions ‐ Number of apartment admissions ‐ Apartment average length of stay

At the state level:

‐ Time of call ‐ Age of client ‐ Zip code of caller ‐ Number of calls requiring transfer ‐ % of successfully transferred calls ‐ Reason call not transferred

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Q15. Describe the preferred tools to be used with the specific populations, including adults, children and youth who have suicidality, violence, mental illness, SUD and co‐occurring disorders. Describe potential tools used for assessing additional vulnerabilities including economic, physical environment, education, food, social context and healthcare (social determinants of health). Mobile Crisis Team (MCT) will screen for risk of suicide using the Columbia Suicide Severity screening tool. This tool is valid for children ages 7 through adulthood including children experiencing negative social determinants of health. A SUD assessment, ASAM, will be used to evaluate the needs of a person presenting with a substance use disorder. In order to provide services to children and adolescents, it is essential that the MCT staff is well training in NH Abuse and Neglect reporting laws to assure that concerns of risk for abuse and neglect are properly reported to DCYF. It is also necessary that the MCT maintain robust and updated information on community resources to support the warm handoffs to meet individual needs. All clinicians must have training in understand the dynamics of domestic violence and also understand its effects on children in the home.

In order to meet the needs of the underserved population of LGTBQ individuals, MCT clinicians must have extensive training in the wide range of gender expression. Staff must have a basic understanding of how societal attitudes towards LGBTQ populations impact mental health. Subsequently, they will need a basic understanding of how people’s comfort in sharing experiences varies and will impact assessment and engagement/rapport.

MCT must have updated information about resources in local areas, including specialty care, peer support, domestic violence resources and services for the elderly as these are essential disposition considerations in crisis assessment and referral. Clinicians must be competent in the use of DSM 5, with specific focus and understanding in diagnosis of gender dysphoria and differential diagnostic considerations.

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Q16. How much money will it cost to provide a fully integrated statewide mobile crisis response teams and how many individuals would your organization be able to serve? You may provide estimated cost information in any format. If helpful, use the table attached. Include costs expected to be associated with standing up and sustaining the recommended model. See attached budget and budget narrative to understand the estimated cost of providing a fully integrated statewide mobile crisis response team. It is estimated that the 10 Community Mental Health Centers will serve approximately 18,000 individuals annually and each CMHC will provide approximately 290 events monthly for a total of 34,800 events annually.

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Q17. Provide a recommendation of funding model(s) to support the ongoing delivery of services associated with this model. Models may be, but are not limited to, a daily rate for a total cost; bundled service rate (identify which services), administrative rate/costs that pass to providers, and or tiered Medicaid rates. In addition, what types of funding sources are available such as private insurance, Medicaid, general funds, etc.? Application of a funding model is very difficult to specifically detail as event‐based services are not predictable, based on the nature of emergency demand and responses. Thus, to ensure that the program does not run at a deficit, a fee‐for‐service model would need to anticipate low volume and high cost resulting in high governmental reimbursement levels. A program that relies on a fee‐for‐service model could fall short of projections if the demand for service is below target or if the population served is uninsured or underinsured. History would indicate that dependence on a mixed payor source of revenue is improbable as based on information from two of the current MC teams’ shows that a significant part of the population served is supported by Medicaid and to some lesser extent private insurance. Availability of first‐party payments is also limited as client resources have proven to be minimal. Alternative Model: This model proposes that each Mobile Crisis Team (MCT) determine a daily rate that would include all of their MCT costs. This method would work as follows: Each regional MCT would estimate their annual costs multiplied by the amount of Medicaid‐dependent costs. That net number would be divided by 365 to determine a daily cost (for Medicaid). The provider would submit that daily cost times the number of calendar days in the month for a monthly/quarterly reimbursement. At the conclusion of each quarter, reconciliation would occur to review actual costs and payor mix percentages. In some cases additional government funding would be required and in some cases a carry‐forward amount would be necessary. Example: Provider “A” has annual MCT costs of of which Medicaid is projected to be 90% of the population (revenue) derived— Divided by 365 days in the year = day 90 days in a quarter; reimbursement = If total quarterly costs come in differently and/or Medicaid penetration comes in differently, then numbers would be adjusted and reconciled. Each year, costs would be adjusted by the index of inflation (CPI) to keep pace with increasing costs for CBHA administration and the mobile crisis teams.

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Q18. Are there additional questions or concerns that are important for the Department to consider with regard to developing and implementing the recommended approach? No answer

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RFI‐2020‐DBH‐01‐MOBIL for STATEWIDE MOBILE CRISIS RESPONSE TEAMS ‐ BUDGET Page 34

TOTALS

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