Thread by @shayshinecastle

Next up: An introduction to the city's alternative (non-police) response team. documents.bouldercolorado.gov/WebLink/DocVie…

Boulder already does co-response (police + behavioral health workers) and that won't stop. They're just adding 2 completely non-police teams of behavioral health clinicians + paramedics.

They'll respond to non-crime 911 calls and the Police Dept non-emergency line, and also offer case management services as followup.

They could handle up to 5,172 calls a year, based on study of current calls, or 431 per month on the high end — 6% of dispatch calls.

The teams could respond to: Loitering, behavioral checks, welfare checks
For example:
- A “person down” call, such as a person laying down for a long period of time in a public space with observers uncertain if assistance is needed;

- Intoxicated persons needing transport to withdrawal management or health care services that are not experiencing a medical emergency;
- Calls for medical checks; and
- Welfare checks for older adults related to non-emergent medical concerns, hoarding, and dementia.

The top avoidable emergency department visits are for behavioral health evaluations (33%) and alcohol intoxication (32%)

It's being called the “Community Assistance Response Team" or CART, but Wendy Schwartz notes that may be temporary.

Tonight's presentation is titled: "Community Assistance Response Team: A Complementary Program to the City’s Current Co-responder Program”

CART = 2 teams of 2 behavioral health clinicians and paramedics
They'll work from 9 a.m. to 7 p.m. (which is when the greatest volume of calls eligible for alternative response come in) M-F

And 2 case managers (to follow up)

What will CART do when they respond?
- Short-term case management/service referrals for people with lower acuity needs;
- Minor medical evaluation/treatment;
- Non-emergency transport to service sites (shelters, pharmacy)
- Assessment for mental health/substance use needs

Schwartz: Behavioral health is a more recent term that experts in the fields use. We used to treat mental health and substance abuse separately, but we've learned they are related.

CART is modeled after Denver's STAR program, and CAHOOTS in Eugene, Oregon. Both of them have been incredibly successful, not only in better outcomes for the folks involved, but also in reducing crime and police violence. 9news.com/article/news/l…

theatlantic.com/politics/archi…

"STAR cost four times less to respond to minor crimes, lowering the average for each offense from $646 to $151."
axios.com/local/denver/2…

CART will cost $60K+ beyond current budgeted amount in 2023 ($965,000)
--> Total cost: $1.025M ($860K ongoing, $165K one-time)
City would hire 2 clinician, 2 case managers and contract with AMR for 2 paramedics

Boulder County is doing this as well (kinda): They're using ARPA $$ to do alternative response, although there's no specific program proposed yet.

How will we know it's working? Unlike with the city's encampment removal program, there are goals! And metrics!

- Save police and fire time (through faster response times for higher-level or more critical emergencies)
- Improve health outcomes for people in emergencies, avoiding emergency room visits
-Cost savings from reduced emergency services

They'll track some of these things:
- Number of times police are called in by CART;
- Number of arrests in CART calls ("jail diversion");
- Satisfaction of people that call dispatch to initiate CART response (and self-report of feeling respected during interaction);

- Percentage of calls/interactions that involve an individual experiencing homelessness;
- Outcomes for individuals participating in case management as part of this program
- Basic info about the individual’s needs identified during the call/interaction
- Basic demographics

- Number of individuals with multiple interactions, and median number of interactions for those individuals.

I don't think they're tracking any of those things for encampment removals. At least I was told they weren't last time I asked.

There are some anticipated challenges:
Potential challenges
- “Missing upstream resources”
- Workforce shortages
- Coordination and data sharing: some things are private

RE: upstream resources, this paragraph really says it all:
"The best intervention and assessments will fail if there is no place to take a person in crisis or no service to refer them to. … Local emergency departments regularly go on “psych divert,” ...

... which means that people in crisis may need to go to another community. This takes up time for first responders and puts the person in crisis in a system that may be unfamiliar to them and less likely to connect them to supports near their home. ...

... Many community mental health centers and private providers have months-long waitlists to begin therapy or see a prescriber.

Systems that work with the most vulnerable community members are also the most under-resourced and have experienced greater staffing turnover ...

... during the pandemic.

Behavioral health provider networks are constrained by payor source, with fewer provider options available to individuals who depend on private insurance or Medicaid to cover some or all of their treatment costs. ...

... Given the shortage of behavioral health providers, these constraints lead to longer wait times or some people going without treatment."

It was a long paragraph.

I'll sum it up for you in one word: Capitalism.

Turns out when you turn health care into a for-profit enterprise, it sucks! For everyone! Who knew? Other than everyone in the rest of the world.

Anyway, back to this program: We want to hire a formal evaluator to refine the metrics and conduct an evaluation of the first-year pilot, Schwartz says.

"Sometimes we're trying to navigate people to services, but the right services aren't there," Schwartz said. "That can include missing mental health resources," those with long wait lists. Housing. Meth treatment.

The program would be up and running by mid-2023, with the release of findings on the first year of operation in mid-2024.

Friend: CART only be for non-criminal; how do we define that? Do violations of city ordinances not count? As example: The tent ban.

Herold: There are some legal concerns we are working through right now.

Friend: Do STAR and CAHOOTS also delineate criminal vs. non-criminal calls in this way?
Schwartz: "Neither jurisdiction says absolutely nothing criminal. ... They say that criminal issues are considered in the dispatch assessment process."

Dispatchers are assessing criminality as well as other compounding issues, Schwartz says. But to answer your question, it's not my understanding that either jurisdiction exclude criminal calls in any broad way.

Friend: Why did we, then? CAHOOTS has been in operation for 20, 30 years; they've got plenty for us to learn from.

Herold: "I don't think there's any hard line on this." The triage is going to be done at the dispatch level.

"I would imagine when this starts, we're going to have a lot of asking a lot more questions than dispatchers are used to," Herold says.

For example, I don't want to say police aren't going to respond to any trespassing calls. "I see no hard lines."

But we do need to consider safety concerns, Herold says.

Friend: What's your vision for the ID'd goals here? If people feel safer with this than calling 911, how much will that way against meeting other goals? I don't want to see the program end if we don't meet all of these things.

Schwartz: We want this program to meet people's needs, and use community resources in a way that makes the most sense.

Friend: "It's hard to measure customer satisfaction in times of crisis. ... I'm not sure how quickly we can get to data that supports that."

Friend: It says this program is for people with low-acuity needs without safety concerns. How would something like suicide fall under that? It's a safety issue and it's not low acuity.

Schwartz: "It depends on what's going on in that call beside the thoughts of suicide."

Friend: Why are we hiring case management, when "I consider that such an obvious health and human services function" — which is the county's lane.

Schwartz: "We put ourselves in that place. ... It's very challenging to have a response program that delves into HHS issues..."

.. and not have that coupled with a tight handoff to services that can help them on an ongoing basis, and not just an emergency basis," Schwartz says.

"That's the fear of our staff of implementing a response program" without that back end of case management.

Friend: There are already orgs doing case management. Why aren't we partnering with them and instead doing it ourselves?
Schwartz: Having a gap is difficult. Our co-responder program had issues with "people falling through the cracks."

Schwartz: "The people working on the front lines in crisis response are telling us this is important, this is critical if we really want to make a difference."

Friend: Who would have oversight of people we hire for this?
Schwartz: HHS for clinicians and case managers. Fire dept for the paramedics.

Brockett: Who is overseeing the program as a whole and determining next steps, ensuring its success?
Schwartz: We've had a collaborative model across HHS, Fire and Police, and we anticipate continuing that.

Right now, our co-response team reports to me. So would new staff.

Even tho they're embedded with police, bc that's where dispatch happens.

Folkerts: I previously called for a CIRT (co-response) and was informed that a police officer would have to drive by first to make sure CIRT was appropriate. Is that typical, or was that specific to my case?

Schwartz: "That isn't our typical procedure."

Folkerts: How do we plan to manage community expectations? What if someone calls in for CART but doesn't get it? Do they know ahead of time?

"It could even be that CART is too busy at the moment," Folkerts says. "It's important for people to know who's showing up before they're at the door."

Herold: The 911 dispatcher would be very clear about who's coming. If the person did not want a police response, we could cancel the request unless it was a safety issue.

Benjamin asking about the proposed hours of operation.

Is it just me, or is everyone taking a really long time to say everything tonight?

Wallach: When we send out a response team, if we don't have a bed for them or facility, what are we going to do with them?

Schwartz: "We're going to deescalate the situation, make that crisis situation resolve in the most therapeutic way possible."

"Then we are going to do everything in our power to connect that person to the resources that do exist in the community," Schwartz says. You're not wrong: There won't always be resources.

"But we want to make sure that situation is as non-traumatic as possible for that person."

"Despite the fact that the program has been done elsewhere, for us it's a leap in the dark," Wallach says. "We're taking a $1M... I don't think it's a risk, but we don't know."

Still supports, but wants solid metrics to ensure it's a good use of $$.

Friend: I want to see us follow the example of CAHOOTS and STARS with all aspects of this program, including case management. "I don't think they're doing it. This seems like a duplication."

Folkerts has a name suggestion: Health Equity Assistance Response Team or HEART

Benjamin: "CAHOOTS and STAR have been around for so long, it would be nice to copy them" and *then* finagle it as we learn. Suggests phasing in case management rather than starting with it.

Winer in favor of Folkert's suggested name. "I'm very excited about this program and will do cartwheels when it starts."

Brockett: To me, it sounds like case managers are critical to the success of the program. Are there ways to partner with organizations doing the work to provide that? Do we need to hire them ourselves?

I do think it's odd that the city wants to hire case managers. There aren't enough of them, for sure, but also *everyone* is having trouble hiring right now, including the city. So why do they keep suggesting new positions they might not be able to fill?

And not just for this... I've noticed this across departments and programs.

It just seems to ignore reality a little bit.

Anyway, back to CHART/HEART. Everyone supports the program, but many opinions on/suggestions for how to go about it.

That's it for this and the meeting.

@threadreaderapp please unroll. Thanks!