The Crisis in Crisis Services

Two things were brought in to much better focus with the “release for comment” of the Mobile Crisis Response “Best Practices” Guidance on 20 October (which as of 10/27 has no comments) – first, it appears that efforts to reign in the growing costs of Mobile Crisis continue, but seem destined to be ineffective due to a lack of actual specificity in the rules and the willingness (ability) of anyone to consistently enforce them.

The description below for “provider qualifications” found in Appendix G of the DMAS Manual appears to be the only substantive description of the “provider requirements” for Mobile Crisis:

Mobile Crisis Response providers must be licensed by DBHDS as a provider of Outpatient Service/Crisis Stabilization (07-006) or DD Outpatient Service/Crisis Stabilization – REACH (07-007) and be enrolled as a provider with DMAS (see Chapter II). Mobile Crisis Response providers must follow all general Medicaid provider requirements specified in Chapter II of this manual and complete DBHDS training for this service as required by DBHDS.

Mobile Crisis Response providers must have an active, Memorandum of Understanding (MOU) or contract with the regional crisis hubs. This MOU or contract must be kept up to date with the DMAS Online Provider Enrollment System. This requirement does not apply to CSBs that act as the regional hub or CSBs providing only emergency services pursuant to section §37.2-800 et. seq. and section §16.1-335 et seq. of the Code of Virginia.

And, perhaps more significantly, the service description avoids any concrete example of providing the service for an individual, who at the time of the call, is on the street, in a convenience store or parking lot, and claims no permanent or even temporary address.  Instead, the emphasis is placed on “meeting the individual where they are.”   As a convenience store parking lot may be the location to de-escalate and assist in preventing acute exacerbation of the symptoms, it is not an ideal location provide the Care Coordination and other intervention in the subsequent hours. 

Two specific issues which have been a source of friction seem to be:

• What appears to be “self referral,”  and
• Utilization of inexpensive hotel accommodations for the individual to permit the provider to provide the services allowed up to 72 hours.

There is an attempt to curb the first by recording the response time and providing data to the “dispatch hub” when the response times are consistently below average the provider will be referred to the regional HUB for a “quality service review.”   

The Document currently out for comment, which is intended to define and promote quality services,  also describes the “best practice” to handoff, when possible to either a CRC (23-hours obs) or a community-based stabilization team.  There is no suggestion (as perhaps there should not be) that providers should not provide multiple levels of cars and be able to move individuals as appropriate among those levels. 

It appears within the levels of oversight authority:

• There is minimal opportunity for DBHDS Licensing to effectively monitor, as their regulations do not contain operational detail (they could establish that every provider meets 12VAC35-105-700, 710 and compliance with the “administrative” regulations re record keeping, etc.
• The “HUB” is designated as the monitor of certain elements, but only to the degree that there is actionable behavior to allow the revocation of the MOU.  Given the inevitable consequence of revoking an MOU, civil litigation on the part of the provider is likely and, therefore, a significant deterrent  to action.
• Finally, the ultimate oversight belongs to the MCOs (or DMAS) and that means multiple standards of oversight and follow-though on any claims that seem questionable. 

Perhaps the only way to curtail what appears to be excessive utilization is:

• to amend the actual regulations to “require” either a shorter window of service provision for Mobile Crisis,
• or referral to Community Stabilization only with the intermediate step of a face-to-face consult with an Emergency Services worker from the local CSB. 

The former may defeat the purpose and the latter will put unnecessary burdens on the staff of the CSB. 

The absence of a  solution is not only putting a strain on the system as a whole, but is adding to the stress on the “988” Call Centers while they are still in their development and growth cycle.   It is critical to the overall success of crisis program that the 988 system be able to accept and process not only high volume, but also a full variety of calls to direct higher acuity calls away from law enforcement to a robust system of crisis care.