The new year is already shaping up to be another exciting time of change for prehospital care. As an example of that, I would like to share my experience riding along with Colorado Springs’ CRT unit.
Created in response to citizens’ mental health needs, the city’s Community Response Team (CRT) is a collaboration between the Colorado Springs Fire Department (CSFD); AspenPointe, a provider of mental and behavioral health services; and the Colorado Springs Police Department (CSPD). They jointly created a mobile mental health crisis response unit empowered to perform psychiatric evaluations and medically clear patients in the field for admittance to mental and behavioral health treatment facilities.
The team responds to calls from the Colorado state crisis hotline as well as 9-1-1 and consists of a CSPD officer trained in crisis intervention, a CSFD paramedic, and a behavioral-health clinician from AspenPointe. Since its launch in December 2014, the CRT has helped patients avoid lengthy emergency department stays and receive appropriate mental healthcare for their conditions, and released police and fire units from being delayed on psychiatric calls.
As part of my ride-along, I sat down with the people who took the initial state grant program and turned it into a sustainable MIH-CP model: Stein Bronsky, MD, is CSFD’s medical director; Mindie Verplank is a nurse-paramedic; Lori Bedel is a licensed clinical social worker; Sean Collins is a captain with the CSPD; and Julie Stone is a lieutenant at CSFD.
What did you hope to achieve with your mobile mental health CRT unit as part of your larger MIH program?
Bronsky: Our philosophy was that if we could duplicate every element from the emergency departments, bring them all into the field, streamline the process, and skip the emergency rooms, then we’d be doing everybody a great service. But we needed the security element, which has been sort of the gem in this. Then also the social work and medical portion.
Honestly I think the best thing about this is how it turned into an equal relationship among the fire department, the police department, and the behavioral health organizations. I think if you were to look back and say, “Who’s benefited the most from this?”, I think everybody’s benefiting. Everybody likes it. There’s no entity that doesn’t support this. But I think the police are the ones that have really recognized the full potential of how we can save them unnecessary manpower going out and dealing with this population.
I remember when we started talking to the police about going and seeing the behavioral patients, their response was, “What does that mean?” They don’t refer to their subjects that way. Once we were speaking the same language, they were able to say, “All right. We’ll try.” The idea was that we would trial it for six months and then assess if it was worth continuing. It was about 10 days later that the police chief contacted our administrator to say, “This is great—we’d like five teams, please.”
Of all the different programs and interfaces with prehospital care I’ve ever dealt with, this was the one program that just hit it out of the park from the second it started. Not all programs, obviously, end up like that.
This started as a state-funded project and has been going on for about three years, right?
Bronsky: Those grants are no longer funding it, so it is considered a sustainable program now.
So is Denver or any other city in Colorado doing anything like this?
Bronsky: Yes. Several cities have visited us to evaluate the program. I know there are one or two smaller places that were able to start up similar type units within Colorado.
It’s hard because it’s a collaborative effort between three distinct entities. There are other programs that have the paramedic and the social worker, or police and a social worker, but not the combination of the three.
Tulsa was the first city outside of Colorado that came, evaluated, and fully launched this exact model.
Verplank: One of the unique things they find is the relationship the Colorado Springs Police Department has with the Colorado Springs Fire Department. That is essential and has been really shocking to some of these agencies coming in. “You put a firefighter and a cop in a van, and they get along?”
So that’s been key. It’s been great as an EMS provider to learn about the legal sides of some of our calls. And I had no idea how many psychiatric-related calls PD took that EMS never even saw. When I hear medics complaining about psych calls now, I’m like, “You have no idea.”
Bronsky: When we were just trying to figure out if it would really be worthwhile to involve the police, we had a paramedic visit the PD and ride along. At the end of that, he came back and said, “Yep, it’s about five to one—they see five to every one we see.”
It’s hard for us to conceptualize that, but that’s how drastic it is on the police side. We just assumed that every time they interacted with a psych patient, they immediately called EMS, which is not the case. They were spending all these man-hours dealing with these people when that’s not really what their skill set is.
Verplank: PD was calling AMR out to do the psych evaluation, but EMS can’t write an M1 [involuntary 72-hour type 1 mental hold] like law enforcement does.
Collins: The correlation was that since law enforcement can arrest somebody and take their freedom from them, then they must also be the best people to put them in protective custody and take their rights. I guess the thinking was that officers are the best people to write the M1 because they already arrest people anyway.
Bronsky: Unlike the other programs, this one had proof literally out of the box. Within 30 days we had an 85% reduction in ED visits. Only a small percentage of those would have previously been dispositioned to a mental health facility.
The police were able to show their man-hours saved right away, and we drastically reduced the number of patients who went to the emergency department.
Verplank: Some of these patients we’ve seen in their homes and environments, had they gone to the ED, would probably have never been put on an M1 because they could present clean-cut. Now [Bedel] walks in and sees how they’re living. They may have no food, or the food they have is rotten; there’s feces all over, or whatever. So even though they might look clean-cut, they aren’t doing well.
Bronsky: By the time you encounter a patient in the field, then pass them on to the emergency department, then on to the social worker, there is so much information that’s lost.
So once the environmental triggers are gone, how can you properly diagnose?
Bedel: I remember walking into a house, and this lady presented well. She was fully oriented. She contained her psychosis, but I started looking around. It was a hoarder house, which isn’t a reason for a hold, but she had a stove with tape on it. There was little food, and the food she had was rotten. There were bugs everywhere, and she clearly hadn’t been using her shower or eating well.
Had she gone to the ER and presented that way, she would have been released to go back home.
Colorado Springs also has a robust system in place compared to a lot of other cities, correct?
Bedel: That’s where we have the partnerships of the psychiatric hospitals too. They’re willing to take Mindie’s medical clearance and my evaluation and do a direct admit. In fact, now we can call them up and say, “Hey it’s us,” and they respond, “OK, what do you have?”
Within five minutes they usually give us a bed, so from the time we contact them to the time we drop the patient off and transfer, it takes an hour or an hour and a half tops.
Verplank: The parameters of our clearance have already been decided. All the partners—hospital system, psych facilities, and obviously the medical director—sat down and agreed on those, and that’s why they will accept field clearance vs. us having to come through the ED.
Bronsky: That was probably the lengthiest conversation. We had to sit down with every medical director and convince them a paramedic can do an adequate field clearance. The initial response was, “Excuse me, what?”
I think that’s probably one of the biggest disconnects in all emergency care: Psych patients come into the ED, and we get these massive workups on them because the psychiatric facilities won’t even talk to you until you’ve done it all. When it comes down to it, the psychiatrists don’t trust the emergency department because they feel as though the ED staff isn’t adequately trained, whereas what they truly need is somebody to simply do a proper evaluation on the patient. The labs mean very little because most of the time you can catch what’s going on just by doing a decent physical assessment on the patient. When we talked to them about what they actually need and what the paramedics were going to do, then they all got on board.
I remember the first patients we dropped off to the psych facilities wanted us to stick around for 20 minutes.
Verplank: They didn’t know what to do with a direct admit. Speed isn’t a metric in the psychiatric world. We explained, “We have to get back out in service.” So they had to become very comfortable with us just literally walking in and saying “Here’s what’s going on with this patient, and now we have to go.”
Bedel: Like what Mindie was saying about the PD and FD—initially this was so outside the box for everybody that they had no baseline to work from. The staff would respond, “Our patients come from the ER, not the streets. What are you doing to us?”
Even sometimes now when I say, “We’ll be at your facility in about 20 minutes,” they respond, “You’re transporting?” I say yes, and you still sometimes hear that “What?” on the other end.
Bedel: The other thing we ran into, especially at the schools, was when they had a student acting out, they just wanted us to take them off their hands. We would explain they don’t meet criteria, so we can’t take them. They’re just acting out, and that’s not mental health.
Verplank: And they would respond, “So you mean you’re leaving them here?”
Bedel: Previously they would call 9-1-1, and PD would come out, and then PD would call for AMR, and AMR would take the problem away. Now we show up and say, “No, this is not the ED’s problem.”
Bronsky: The same concept happened with the traditional nursing home patients, where they’d call and say “She’s not acting right” or “He doesn’t look right.” Previously the fire department would come in, scoop them up, and leave.
Now when we come in, we say, “We’re going to assess this person and call their POA. We’re also going to contact their doctor to find out what their baseline is.” And they would respond, “No, you aren’t, you just need to take them and leave.”
After we make the calls, we’ll often come back to them and say, “Yes, this is this patient’s baseline” or “This is nothing that has to go to the emergency room.” That just rocks their world, because they feel like they’re not getting the traditional service they used to get. And they aren’t, but it’s the right thing to do.
Bedel: They’ll say, “Dr. Thompson wants his patient on an M1.” And we’ll respond, “Well, then, Dr. Thompson needs to come down here and assess and get us some paperwork,” because as far as we know, Dr. Thompson doesn’t exist.
Obviously we aren’t this sarcastic with them, but we are trying to educate them: This is how it really works—these are the laws. It’s been a huge education on everybody’s part.
Do you go to the memory care facilities at all?
Verplank: We’ve been able to stay away from that because it’s not appropriate. It’s not psych.
Bronsky: We have other programs that deal with that.
Verplank: But we’re more than happy if an officer responds to a call like that and wants to call us for traditional advice.
So what was the biggest eye-opener for you, Lori, leaving your hospital psych office and going into the field?
Bedel: For me it was just learning. I feel like I’ve learned so much on the PD side. I just learned so much as far as what they can and can’t do legally. Their hands are tied too.
On the medical side I’ve developed a better understanding of what truly is a medical issue versus a mental health issue. So for me just learning both sides of that has been huge, because I was in this mental health box, sitting in the ER, evaluating my patients in a cozy little environment.
And now I’m seeing them in their environments. Going into people’s homes or seeing them in the community is totally different than what you see in an ER or even an office. These people who come to an office or even in the ER, they’re stabilized because they’ve been medicated or removed from their trigger point.
When I used to see them in the ED, they were often given Geodon, and the psychosis was largely gone by the time I’d see them. I would walk into an eval room and say, “Why are we seeing this person? They look fine to me.” When we see them on the street now, it’s totally different.
We’ve also developed a better recognition of true psychosis versus what a meth reaction looks like. We can look at a call screen for two minutes and be pretty sure it’s meth before we even see the patient. There have only been two that shocked us where we thought drugs were involved rather than a psychosis.