How Austin Handles Mental Health Emergencies
Police, EMS, and Integral Care work together to serve people in psychiatric crisis
When a police officer brings someone to the Judge Guy Herman Center for Mental Health Crisis Care, they're greeted in a clean, white, and sterile space that does not lack for warmth. The officer is offered a cushioned seat and granola bar while an on-call nurse whisks the potential client away to determine whether they're in the best place to receive care. So long as no pressing medical needs are found, the officer is free to go.
One of the Herman Center's many goals is to get law enforcement back to their patrols within 15 minutes of dropping off any individual put on emergency detainer. In Texas, a peace officer emergency detention, known shorthand as a POED (or just ED), can only be issued after an officer determines a person in the throes of a mental health crisis represents an immediate risk to themselves or others, or is deteriorating mentally to the point where they're unable to make safe choices. (An example, said Integral Care practice administrator Laura Wilson-Slocum, would be someone experiencing delusions about crossing a highway to "save Austin from the apocalypse.") Once that decision is made, the officer detains the person and transports them to a facility for psychiatric care. Tracy Abzug, Herman's practice manager, said her facility has been meeting that 15-minute mark. "We recognize that our interaction with officers directly informs how they interact with people in mental health crisis," she said.
Once they get checked out, clients are taken to the exam room for a skin check, urine test, drug screen, and Breathalyzer, so staff can tease out any contributing factors to their crisis. The client is offered a private shower and fresh clothes. Wilson-Slocum believes a shower offers its own therapeutic benefits, and could be the first time in hours that the client has been alone. The showerhead is flush with the wall. The curtain bar breaks away when the slightest bit of pressure is applied. The pipes from both the sink and toilet have been filled with metal to ensure no ligature points can be accessed. "We recognize it's one of the worst days of their lives and they may not want to be here," said Wilson-Slocum. "Tracy and her team really took care with how to best create a safe environment while still being therapeutic."
Finally, the client is taken to their private bedroom on the extended observation unit, where they'll spend the next 48 to 72 hours recuperating. There are four beds on the unit, each with their own bathroom. The bed frames are made of thick plastic, and the mattresses resemble those found in a bunk at an expensive camp. The walls are bare, but the rooms get a healthy dose of diffuse, natural light. Down the hall is a day room where warm meals are brought in three times a day. Ideally, EOU patients transfer to the west side of the center once their detainers have been lifted. On the crisis residential floor, clients move around more freely. The community area has a TV, numerous books, arts & crafts options, and a private phone booth area. Guests can ask a staff member to accompany them to the outside patio. The floor's 12 bedrooms remain separate, but the bathrooms are communal. In October when I visited, the space was decorated for Día de los Muertos.
The west side of Herman is less restrictive than the EOU, and features an open workstation for staff and nurses, which Abzug said is "beneficial" because it allows clients to more freely interact with a staff member when they have a need. On weekday mornings, Edward, the cook, can be heard chopping vegetables for that day's meals. A registered nurse and one licensed vocational nurse are on duty at all times, and counselors are on-site from 8am to 10pm. Case managers who help link clients to ongoing care are in house seven days a week, as are a handful of nurse practitioners. Through these channels, the Herman Center, which is located on the northeast corner of Montopolis and Ben White and named to honor Travis County Judge Guy Herman's commitment to improving the lives of residents living with mental health issues, works to resolve the client's crisis episode, creating a personalized recovery path and providing resources to prevent future crises.
What a Crisis Looks Like
There's no cut-and-dried definition of what a crisis looks like. Wilson-Slocum called the term "subjective." Members of the Austin Police Department's Crisis Intervention Team said "it changes per individual – someone might not have a diagnosable mental health condition, but they may still be in crisis."
They should know: The Crisis Intervention Team is the one tasked with administering follow-up for each of the department's mental health calls. Pressed to provide a specific example of what a mental health crisis could look like, Senior Officer Jaime Von Seltmann cited a young adult, on their own for the first time, who gets their first flat tire while driving on MoPac. "That could be enough to send the person into full-blown crisis," she said.
Individuals also face repeated or chronic crises. "The aliens attack them nightly," explained CIT Sgt. Michael King. "These cases are the ones we deal with repeatedly. And they're the hard ones, because I don't know if we're ever going to be able to help them. We just do the best we can. What's happening to them – that's real. You have to remember that."
Anyone can experience a mental health crisis. Wilson-Slocum said it's crucial for mental health professionals to convey this bit of information to law enforcement, paramedics, and civilians during mental health awareness and de-escalation trainings, which she frequently facilitates as part of Integral Care's services. But some folks are more prone to repeated crises; specifically those living with severe mental illness (like major depressive disorders, bipolar disorders, and schizophrenia disorders) or people with a long history of trauma, especially sexual trauma.
According to the National Alliance on Mental Illness (NAMI), nearly 10 million adults in the United States are currently living with severe mental illness. But 43.8 million Americans will experience a mental health issue in any given year. "Anyone can experience a mental health crisis," Wilson-Slocum reiterated, "and the likelihood that all of us experience one mental health crisis in our lifetime, I would say is very high."
In Austin on any given day, APD receives between 3,000 and 4,000 service calls. It's unclear how many of those are mental health cases (not everyone who calls makes clear that they're experiencing a mental health crisis while on the phone), but in 2016 alone the six officers and one sergeant comprising the Crisis Intervention Team received nearly 12,000 reports, 5,500 of which were emergency detainers. Up until August, when Integral Care opened the Herman Center's doors for the first time, those 5,500 folks likely suffering from a psychiatric crisis were taken to either a nearby emergency room, or a psychiatric hospital (if a bed and insurance were available). But ask anyone, from the CIT officers to those who work at Integral Care, and they will tell you that an emergency room is not the best place for someone in a psychiatric emergency. "There's always something exciting going on," said Dr. Albert Gros, chief medical officer at St. David's South Austin Medical Center, which boasts the busiest emergency room in Central Texas. Gros described his 47-bed ER as a "goldfish bowl" with no privacy. "That's the last thing you need when you're in an agitated state or having a psychotic break."
For years, Austin lacked intermediate intervention options, forcing first responders to choose between leaving an individual in a state of crisis within their community (if their symptoms fell short of ED standards) or taking them to a bustling and costly emergency room. Wilson compared the previous options to clothing sizes: "You had an extra large or an extra small, and just everyone had to wear it."
Finding Red Flags
Von Seltmann has served on the Crisis Intervention Team for six years. In this line of work, she said, the phrase "it takes a village" gets taken seriously. Crisis intervention is about institutions working together, "because that's what it takes to get somebody healthy. If there's gaps, that's when we see someone relapse."
The Crisis Intervention Team was founded in 1999 as APD's response to intense media scrutiny after a series of officer-involved shootings ended the lives of several people living with mental health issues. The incidents sparked a realization at APD: Officers needed more robust guidance on how to de-escalate tense situations – and, more so, how to recognize when someone might have a mental health issue. Today, the unit's officers function primarily as secondary responders, by looking for "red flags" in patrol reports. These include signs of hoarding, someone who isn't getting out of bed or might not be eating or bathing, and erratic behavior. "If I have that gut feeling something's just not right," said Von Seltmann, she and her colleagues will make a house call to suss out what is happening, and how their unit can help.
The team also leads cadet trainings on mental health with the help of Integral Care and NAMI Austin. Though the state recently increased law enforcement's mental health training requirement from 16 hours to 40, APD cadets have been receiving 40 hours for years, said King. Officers can additionally elect to take a weeklong mental health peace officer course through the Texas Commission on Law Enforcement.
State law grants all civil service officers the ability to issue emergency detainers, but APD has opted for a heightened level of selectivity. Only officers who've taken the additional training can write EDs, for which they receive a small stipend. Currently 162 of the 1,800 sworn officers are receiving the pay incentive, but King says that number does not reflect the numerous officers who've taken the training and promoted out of patrol or are no longer receiving additional pay.
Regardless, King attests that every cop at APD doubles as a CIT officer, because all of APD is trained in crisis intervention. He credits the department's commitment to the community and the intensive training cadets receive. "We train all our officers because it's not a matter of if they're going to come into contact with somebody who has a mental illness, it's a matter of when – in their shift," said Von Seltmann. Officer Rocky Reeves, who joined the team in September, seconds that sentiment. Some days, during his time spent on patrol, he said, "I would do nothing but mental health calls all day."
It Takes a Village
Of the 12,000 reports the CIT received in 2016, 6,500 did not result in emergency detainment. Because those individuals are taken to a medical professional, it's these non-ED cases that make up the bulk of the unit's work. Some get cleared without much trouble. Others require greater community collaboration. According to Von Seltmann, a large portion of CIT's reports come from friends or family members who've grown worried about a loved one and don't know where else to turn. "They've been down this road before and they can see the train coming, but it hasn't really gotten to the level where we can intervene," she said. "It's a lot of, 'Okay, now what do we do?'"
Most of the time, they call MCOT, Integral Care's Mobile Crisis Outreach Team. The team is made up of two sections: one dispatched to calls through Integral Care's crisis hotline, and another that responds to first responders. They're master's-level clinicians trained to go into the community to treat a person in need of mental health services who is unable or unwilling to seek treatment on their own. While other cities rely on mobile teams, what sets Travis County's apart is its extended care. For each consumer, MCOT can follow up with counseling and medication services for up to 90 days, with the goal of connecting the client to long-term treatment. Wilson-Slocum said the practice "removes a lot of barriers and impediments to people seeking services on their own."
MCOT was originally developed in 2006 to better serve people in crisis without interfering with law enforcement or paramedics, who Wilson-Slocum noted are "not mental health experts." As the county's mental health authority, Integral Care felt the team should be the first responders for mental health crises. MCOT grew in 2012 when the state approved additional funding. One year later, they began working with APD and responding to officers on patrol.
Because they're countywide, EMS, the Travis County Sheriff's Office, Lakeway Police, the Department of Public Safety, and TCSO administrators at the county jail can all request MCOT's services. Like the Herman Center, MCOT aims to release first responders within 10-15 minutes and succeeds 85-90% of the time. Julie Guirguis, an MCOT team lead, said each of the 33 full-time staff members (and one part-timer) responds to two to three calls a day, on average. For fiscal year 2017, they served 4,563 unduplicated individuals – not including repeat visits.
For Austin/Travis County EMS Division Chief Andy Hofmeister, MCOT was a welcome addition to the first responders' lineup, which he now refers to as the "trifecta." Until the mobile crisis team partnered with EMS in 2013, Hofmeister grappled with the lack of places to take individuals experiencing a mental health crisis – torn between leaving them in the community with little support, or taking them on an expensive ride to an ER despite there being no medical concerns. Hofmeister has been an advocate for more robust mental health services for years. In 2009, driven to better serve EMS "frequent users" (people who call EMS multiple times each month), he began the Community Health Paramedic Program. CHP works with repeat, low-priority callers to link them with ongoing care in order to reduce or eliminate their dependency on emergency services. Today, he also leads a paramedic's course on mental health first aid and is working toward incorporating additional mental health training for EMS staff.
With the expansion of MCOT, a much needed gap in the county's continuum of care was filled. But it didn't solve the issue of where to take folks on emergency detention who don't require pricey ER stays or longer, more restrictive (and expensive) inpatient care. In 2013, in hope of sussing out a solution to this missing level of care, St. David's Foundation led a group of local mental health stakeholders on a field trip to Lufkin, Texas, for a visit to the Burke Center for mental health services. After studying their extended observation unit, stakeholders agreed the Lufkin model, from which the Herman Center is derived, would fill a critical gap in Travis County's local mental health safety net by offering an intermediate level of care in between MCOT and restrictive inpatient stays. Together, Integral Care, St. David's Foundation, and Central Health created the Herman Center. St. David's funds the standalone facility, and Central Health leased the land to Integral Care, which staffs and runs the space.
There are less than a dozen facilities like the Herman Center in Texas, and it's the county's first and only non-hospital setting that takes folks on emergency detention. Aside from those, Herman can also accept voluntary referrals from the mobile crisis teams and Integral Care's outpatient clinic Psychiatric Emergency Services, as well as voluntary and involuntary emergency room transfers. Incoming clients just have to meet Herman's criteria. Wilson-Slocum explained that because it's not a hospital, Herman cannot accept people with significant medical or wound care needs. Nor can patients be actively engaging in violent behavior. This is not for philosophical reasons, Wilson-Slocum told me. "We believe people engaging in violent behavior in crises deserve services just as much as anyone else." But logistically, Herman cannot administer restraints; those folks require a higher level of care. She also emphasized that most people experiencing a mental health crisis are not violent.
The philosophy behind Herman, said Wilson-Slocum, is that "most people experiencing a mental health crisis, even if they're on an emergency detention, can usually resolve the worst, most destabilizing part within 48 hours." This negates the need to send folks to a psychiatric hospital, which is more costly and more restrictive. Wilson-Slocum said consumers are unlikely to benefit from an ER stay due to lack of specialized care – though Gros did say that all three Travis County St. David's locations now use telepsychiatry, which allows those detained to video conference with a psychiatrist and start therapy immediately.
Because of Herman's relative newness to the county's continuum of care, stakeholders remain uncertain of the impact it will have. King, who's been vocal about his appreciation for Integral Care and its work, points to simple math: Herman's EOU (where EDs are taken) only holds four beds "when we're dealing with 5,500" clients. Gros said his ER has served approximately 200-250 ED patients each month for nearly half a decade. The difference now is that the stay is shorter. Previously, ED patients would stay at South Austin Medical for an average of four to seven days due to lack of resources. Now there's a much faster turnaround, with ED stays reduced to 24-48 hours before they're transferred. Von Seltmann said she's personally seen an uptick in hospital transfers to Herman. As of Nov. 1, Abzug said Herman only once had to turn someone away due to lack of beds.
The question now is whether Travis County's continuum of care is growing at the rate that's needed. CIT's numbers show a large jump in mental health reports made by officers in the last seven years – from 7,881 in 2010 to just shy of 12,000 in 2016. King and Reeves credit the majority of the increase to better officer training, but Gros isn't so sure. Regarding Herman's goal of clearing up emergency rooms, he said he hopes to see a decline in the number of EDs. But he added that as Austin continues its rapid growth, "we may actually be doing good to break even, and might actually avoid an increase."
But what happens to people after they leave Herman, and when MCOT's 90-day follow-up ends? One of the biggest challenges the center's staff face is creating a reliable discharge plan to keep clients on a track to sustained recovery. Because Integral Care offers so many services, clients can smoothly access the outpatient clinic or MCOT. But because both of those methods only provide temporary aid, the goal is to link each client to ongoing care and medication. Staff help uninsured clients enroll in the Medical Access Program to cover medications and assist in setting up appointments and figuring out transportation.
Sometimes that's enough, but as King notes, it's still voluntary. With Herman's opening, Austin's front-end services have improved a great deal. But what CIT officers worry about is the lack of "back-end" services and long-term care. "We can do all the necessary steps, take them to the facilities, help them see the doctors, but there's no guarantee what's going to happen once they're released," said Reeves. "Because the long term, days where you put people in an institution forever, that's over." Asked if that wasn't a good thing, Von Seltmann spoke up: "I think that back then the pendulum was swung to where if someone breathed mental health, then they would throw them into an institution. Now the pendulum has swung the other way, and there's got to be a happy medium."
Whatever the solution, NAMI Austin Executive Director Karen Ranus believes Austin is moving in the right direction to support folks who experience mental health complications. "Here's the good news," she said. "Integral Care, NAMI, APD, the Sheriff's Office – we're all working together in ways we never have before. It's a mammoth, complex issue, but if we all work together and challenge each other sometimes, we're on the right track."
Anyone in crisis can call Integral Care’s 24/7 hotline (512/472-HELP) to speak with a qualified mental health professional. Walk-ins are also welcome at the Psychiatric Emergency Services clinic, 56 East Ave.