CasaPacificaChildrensMobileCrisisOverviewOAC October2015

Overview of Casa Pacifica’s Children’s Mobile Crisis Services October 2015 Casa Pacifica Mission: Casa Pacifica provides hope and help for abused, neglected or at-risk children and their families. Casa Pacifica Vision: Casa Pacifica will lead the services sector in promoting healthy outcomes for children and in strengthening families Casa Pacifica Approach: We meet kids and families at the most challenging times of their lives and help them overcome some of life’s most difficult circumstances – abuse and neglect, complex emotional and behavioral issues, and family crises. We restore hope, help children find joy in daily living, and improve families’ chances at making a better life for themselves and at finding a place in their community where they can be successful. Casa Pacifica is committed to children unconditionally over time and through all of life’s ups and downs. Core Values: Respect, Integrity, Courage & Compassion  We value the dignity of each individual.  We respect the culture and community of every client we serve.  We practice ethical and data-based decision-making.  We support each individual’s effort to achieve full potential.  We foster an environment of trust and mutual respect. Summary: Casa Pacifica operates two mobile crisis response teams designed to serve children and youth exclusively; one operates within Ventura County; the other within Santa Barbara County.  Both programs are nationally accredited by the American Association of Suicidology (AAS); as such, they operate as leaders in the field of suicidology at the local, state, and national levels.  Staff work collaboratively with law enforcement, County partners from Behavioral Health, Child Welfare Services, Juvenile Justice, local school districts, and a child/youth’s existing treatment team.  Our teams collaborate with community partners to ensure a family is linked to services. Services are available and designed to assist a youth and family in crisis and can be accessed by the general public.  The Ventura County program is the larger of the two programs. While they share many of the same program elements, it is important to note that differences exist in how they are operated in each of the Counties. An overview of the two programs and their respective challenges are outlined on the following pages. Goals of Children’s Mobile Crisis Teams:  Reduce danger and restore safety to youth and families by providing immediate support when there is danger of harm to self or others;  Keep youth in the community in the least restrictive setting; preferably in their homes;  Provide time-limited follow-up services to develop coping strategies that promote safety in the environment and linkage to community resources. P age 1 | 10 Ventura County: Children’s Intensive Response Team (CIRT) Overview: The Children’s Intensive Response Team (CIRT) is a mobile crisis response service, available to all Ventura County children and youth under the age of 18. CIRT is available 24 hours a day, seven days a week, 365 days per year, under contract with Ventura County Behavioral Health (VCBH) since March of 2007. CIRT delivers quick and accessible service to families by providing specialized crisis intervention and in-home support and linkage to county mental health services or other appropriate assistance. By working in collaboration with the child’s existing service providers, CIRT seeks to keep kids and families safe in their homes and communities and avoid psychiatric hospitalization and use of other public resources, such as law enforcement. Services may be provided over the phone as the initial emergency call is taken (e.g., de-escalation and linkage) or in person (e.g., emergency mental health assessments, assessments for inpatient psychiatric hospitalization, follow up safety planning and safety monitoring, collaborative introduction meetings). CIRT services can last up to 14 days and all open cases receive linkage and referrals based on a family’s need. Staff are available to respond to a crisis in person usually within 60 minutes. Emergency services are provided irrespective of insurance availability or ability to pay. Post-crisis, follow up services for up to 14 days are available to individuals with Medi-Cal and the uninsured. CIRT serves youth engaging in behaviors that put him/her at risk of out-of-home placement—if there is a child in need, we respond. Examples include:  Suicidal Ideation/Behaviors  Severe Self-Injurious Behavior (e.g., cutting, choking, head banging, overdosing)  Homicidal Ideation/Behaviors  High-Risk Behavior (e.g., running into traffic, grave disability) If necessary, CIRT has the authority to facilitate an involuntary psychiatric hospitalization for a child or youth for up to 72 hours. Youth (and anyone concerned about a youth) experiencing a mental health emergency may access CIRT via the 24/7 crisis hotline, 1-866-431-2478. P age 2 | 10 CIRT in Real Time: It’s Monday morning… 9:06 am: Caller is a school counselor requesting an assessment for a 9-year-old female and her sister following her teacher finding a note that fell out of her backpack “I just want to die, I can’t go on.” The CIRT team responds and learns that client is living in a multigenerational home and discloses years of molestation. CIRT determines hospitalization is necessary to address suicidality. Child welfare initiates an immediate investigation and upon discharge from the hospital client is safely placed in a residential treatment program. 9:32 am: Caller is a school resource officer requesting an assessment for a 14-year-old, transgender female who is making homicidal threats toward another student. CIRT responds in person and concludes youth meets criteria for an involuntary hold application for Danger to Others. 10:11 am: Caller is reporting her 13-year-old son is being aggressive and acting "ridiculous. He doesn't understand and he won't listen or do what he's told." Mother reports that he’s started carrying knives regularly and threatened her with one earlier this morning. CIRT calls law enforcement to physically stabilize the scene, responds in person, and is able to create a plan for safety and keep the youth in the home. 10:27 am: Caller is reporting that his daughter has run away and is "possibly on drugs" and states "I cannot leave work again today. Something needs to be done." The CIRT team contacts and collaborates with local law enforcement. 10:35 am: Caller (charge nurse) from local hospital requesting an assessment following the medical clearance of a 12-year-old patient who attempted to overdose on Tylenol in an attempt to end her life. The CIRT team responds and after speaking with the client and her mother determine that she would benefit from an extended psychiatric evaluation and is placed on a 72-hour hold for Danger to Self. 10:49 am: Caller is a student who learned of another student at his school who has committed suicide. He is feeling sad and confused. The CIRT team responds to provide support and assess if a 72 hours hold is necessary. The CIRT team determines that a hold is not warranted but spends time safety planning and providing resources to the youth and parent who has also been called to the school. 11:23 am: Caller is a therapist from the community who received a phone call from the parent of her 8 year old client. Parent was upset that her son was refusing to go to school and kicking holes in the wall. The CIRT team enlists the collaboration of a CIT officer and awaits their determination that a face to face assessment is warranted. P age 3 | 10 What happens when a call is placed to Crisis Hotline? Staffing: CIRT uses data-driven scheduling to maximize our staffing during peak demand times. Since we work with school-aged children, it is not surprising that our busiest times are Monday through Friday from approximately 9a to 8p when school is in session, which is why we have the highest level of staffing during that time period. On any given work day during the daytime hours, we have a total of 2-4 clinical staff working staggered schedules to respond to a child in crisis, as well as 1-3 support positions (e.g., parent specialist, case manager). While this may appear to be a robust staffing pattern, during peak months, such as October, a majority of staff can be out in the field and are often delayed in their ability to respond to another crisis if they must stay with a child during the search for an inpatient psychiatric bed, if that determination is made. On overnights, weekends, and holidays the program has only one clinical staff on a shift – who must juggle the hotline calls and all in-person responses simultaneously or with a delay. P age 4 | 10 Ventura County CIRT Hotline Calls by Hour of Day 2011-2015 1000 900 861 832 816 784 777 800 746 743 681 700 637 639 613 600 518 491 500 408 400 327 300 239 200 164 113 102 119 75 100 57 40 47 0 Ventura County/CIRT Volume: P age 5 | 10 Impact:  The increase of hotline activity without an increase in technology, funding, or staffing has resulted in a cap of our ability to respond in person.  The volume of our crisis calls have steadily increased since we began, with a 102% increase over the past four fiscal years.  Due to recent protocol changes within Ventura County (beginning in May 2015), we are currently experiencing unprecedented volume (e.g., busiest September on record, preliminary data suggest a record October, as well). CIRT now responds to 100% of all law enforcement and emergency room calls without screening or hotline-based intervention. Four completed suicides of high school teenagers in Ventura County in the past month has had increased hotline calls and in- person assessments for schools in those regions. Service Gaps & Proposed Solutions:  Answer all calls with a robust, technology-driven call center to ensure a zero fail rate. o CIRT currently manages the consistently increasing hotline call volume with a single iPhone, which has maximum capacity of two simultaneous calls before individuals are directed to P age 6 | 10 voicemail. There are no dedicated hotline operators—answering calls is a shared duty of all team members, often having to be juggled while serving other clients in person.  Texting and instant messaging capabilities. o Research shows that youth crisis lines reach more people in need when they have a variety of preferred means of communication available—persons of all ages report continual reduced preference for telephonic communication year over year.  In-home intensive prevention/proactive services. o Prior to 2014, CIRT was able to assess and serve youth on the verge of crisis who were not imminently homicidal/suicidal. If someone was presenting with an increase in mental health symptoms and was not currently linked to resources, CIRT could provide an assessment and 30-59 days of in-home therapeutic intervention, resourcing, and case management with the goal of early intervention to reduce symptoms before they escalated to the point of lethality.  Follow up services regardless of insurance. o While CIRT used to be able to provide 30-59 days of clinical and behavioral follow up services for any and all service recipients, contract limitations narrowed follow ups to only be available for those with Medi-Cal or no insurance in 2013.  Follow up services beyond 14 days. o In 2014, the scope of CIRT services was narrowed further in that follow ups now had a maximum duration of two weeks for those that qualify. With the time constraint, this reduced CIRT’s ability to help stabilize a client, link him/her to longer-term supports (e.g., the county mental health system), and stay open to client until a warm handoff could occur.  Utilize parents with lived experience to help parents in the moment and aftermath of the crises. Procure funding to provide parent support for every case, whether in the hospital or at home.  Provide intensive in home based services. Keep the child with their family. Develop and implement safety plan including removal of any/all dangerous objects. Bring in other natural supports (grandparents, faith based community.) Set up specific linkages and referrals and help facilitate the family’s ability to access (set up appointment with pediatrician or psychiatrist; deal with housing issues if they are pertinent; make sure there is food in the house or if needed, help family access food services; etc.) Provide therapy for any/all family members who would benefit (siblings, family, couple, or client). Provide ongoing crisis assessment and crisis intervention for the client. ~~~~~~~~~~~~~~~~~~~~~~ Santa Barbara County: Safe Alternatives for Treating Youth (SAFTY) Overview: The Safe Alternatives for Treating Youth (SAFTY) team is a children’s mobile crisis response service available to all Santa Barbara county children and youth age 20 and under who are experiencing a psychiatric emergency. Through a contract beginning in 2005 with Alcohol, Drug and Mental Health Services (ADMHS) of Santa Barbara county and in collaboration with Crisis And Recovery Emergency Services (CARES) adult mobile crisis team, Casa Pacifica SAFTY team provides crisis services 24 hours a day, seven days a week, 365 days a year. Crisis situations are handled by phone and in person. The program design includes an in person response within 60 minutes, when clinically indicated. However, limited resources coupled with the travel distance from one end of the county to the other, often results in a less than optimal response time. This is P age 7 | 10 an ongoing struggle for the program. SAFTY crisis response services are provided irrespective of insurance or ability to pay. SAFTY’s goal is to prevent psychiatric hospitalization, detention in juvenile detention facilities, or placement in out-of-county facilities and to provide linkage to appropriate mental health services. SAFTY program is designed to help preserve families and strengthen communities. Again, due to increases in call volume and the need for in person responses, without the corresponding increase in funding, this becomes a daunting task for program staff. SAFTY services are for any youth age 20 or under in Santa Barbara County that is engaging in behaviors that put him/her at risk of hospitalization or out-of-home placement. Example include:  Suicidal or self-harm ideation or behaviors  Aggressive behaviors towards other at home or in the community  Other unsafe behaviors related to mental illness. SAFTY services may be provided over the phone through our crisis hotline which was designed to provide immediate telephone support, assessment, and when warranted an in-person response. SAFTY also provides emergency mental health assessments, including 5150/5585 assessment and authorization. These services are often hampered due to limited resources to meet an increasing demand as evidenced by increase in call volume. Supportive efforts are also provided, when resources permit, through targeted case management, collateral, evaluation and plan development to provide linkage to community services. For MediCal recipients, SAFTY has the ability to provide Proactive in-home cognitive-behavioral therapy to address the at-risk behaviors. SAFTY proactive therapy services utilizes a time-limited in-home treatment that targets crisis reduction, which includes 1 assessment with treatment plan and 8-16 therapy sessions. Staffing: SAFTY has similar data driven scheduling, we operate out of two offices in Santa Maria (North County) and Santa Barbara (South County). SAFTY has a total of 7 full-time responders responsible for covering the entire county. SAFTY does not have parent partners or case managers on staff, so those roles are often filled by our clinicians with support from MSW student interns, whenever possible. The SAFTY program has similar challenges in Santa Barbara County operating the program with one person on evenings, weekends and holidays who is responsible for responding to crisis line calls and providing in person assessments for the entire county. P age 8 | 10 P age 9 | 10 SAFTY Service Gaps and Opportunities for growth:  Proactive services for all clients with any type of insurance, including no insurance  Follow up: provide up to 60-90 days of follow up for all client to ensure linkage to appropriate services and preventing hospitalization cycle  hospital privileges in all areas of the county  funding for on call crisis workers in each geographic area or at least SM and SB, 24/7  Competitive salaries for crisis workers, safety stipend in additional to on call stipend  crisis stabilization beds and respite especially in North county  Children’s crisis residential beds within SB county,  Community education/training for other providers, families, law enforcement regarding crisis intervention and services available Given the Mental Health Services Oversight & Accountability Commission’s commitment to improve access to effective crisis services for children and youth, the Central Coast region of California, with both its community based organizations and its partnering county agencies, is well positioned to address the gaps in the continuum of care for children, youth and their families in crisis. P age 10 | 10