Editor’s Note: The American Rescue Plan (ARP) Act enacted on March 11, 2021, establishes a state option to provide community mobile crisis intervention services for a five-year period beginning in April 2022. As an incentive to state adoption, the law provides for an 85 percent enhanced federal matching rate for qualifying services for the first three years of state coverage.1 To further encourage states, ARP also includes $15 million in state planning grants to support their efforts to develop a state plan amendment or waiver request (e.g., Section 1115, 1915(b) or 1915(c)) to take up the option. The new mobile crisis provision arrives just as many states and localities are exploring strategies to address the worsening behavioral health crisis, as well as preparing for implementation of 988, the new national hotline for behavioral health crises. For states and localities reviewing their policing procedures, the new option could also be used to support state efforts to offer more resources to police responding to behavioral health crises—or even entirely avoid the need for law enforcement to respond.
In a new “Expert Perspective” for the Robert Wood Johnson Foundation’s State Health and Value Strategies program, summarized below, Manatt Health examines key questions around ARP’s new state option to invest in equitable, comprehensive and integrated crisis services that connect individuals in behavioral health crises with specialized, appropriate behavioral health treatment. Click here to read the full “Expert Perspective.”
What Are Community Mobile Crisis Intervention Services?
The Substance Abuse and Mental Health Services Administration (SAMHSA) National Guidelines for Behavioral Health Crisis Care distill the elements of a crisis system into three components with linkages to broader behavioral health continuums of care:
- Regional or statewide crisis call centers coordinating in real time;
- Centrally deployed, 24/7 mobile crisis; and
- 23-hour crisis receiving and stabilization facilities.
Using this model, the regional or statewide crisis call center triages a call and dispatches a mobile crisis unit to respond to an individual in crisis. Mobile crisis teams—comprised of qualified professionals who are trained to de-escalate and treat individuals in crisis—work to assess and stabilize individuals experiencing behavioral health emergencies in the least restrictive settings and divert individuals with mental illness from jail and emergency departments to crisis receiving and stabilization facilities and other community-based treatment.2, 3 Mobile crisis teams enable states and localities to begin to shift away from relying heavily on police, many of whom are insufficiently trained in behavioral health crises, to other trained first responders.4
Why Are States Expanding Mobile Crisis Intervention Services?
The mobile crisis state option is one critical tool available beginning in April 2022 to invest in a comprehensive and integrated crisis infrastructure that will:
- Stabilize individuals in crisis;
- Connect them to follow-up behavioral health services;
- Reduce the stigma associated with behavioral health crises; and
- Lessen the reliance of communities on police as first responders.
Investing in a comprehensive crisis system that prioritizes behavioral health treatment can also help states and localities better support individuals residing in under-resourced communities. In addition, this option can augment states’ efforts to ready their behavioral health crisis systems for the establishment of 988 as the national suicide prevention and mental health crisis hotline in July 2022.5
What Are Key State Questions on the New Option?
1. What Are Qualifying Community Mobile Crisis Intervention Services Under ARP?
ARP defines “qualifying community mobile crisis intervention services” as services that are available continuously and provided in a timely manner by a multidisciplinary mobile crisis team that is:
- Comprised of at least one behavioral health professional who can conduct an assessment, as well as other professionals or paraprofessionals with appropriate expertise in behavioral health crisis response;
- Skilled in trauma-informed care, de-escalation strategies and harm reduction;
- Trained to provide screening and assessment, stabilization, and de-escalation, and coordination with health, social and other supports, as needed; and
- Able to maintain relationships with relevant community partners, including a range of medical, behavioral and crisis providers.
2. What Are Some of the Promising Models for Mobile Crisis Intervention Services?
There are a number of different crisis response models that are funded through a combination of Medicaid, state and other funding and leverage different professionals based on community need and workforce capacity:
- Mobile Crisis Teams. Mobile crisis teams comprised of qualified professionals respond within specified time frames, depending on the urgency of the call, and provide on-site crisis management through assessment, de-escalation, consultation and referral, with post-crisis follow-up to ensure linkage with recommended services.
- Community Paramedicine. Community paramedicine programs expand the roles of paramedics and emergency medical technicians (EMTs) to provide preventive primary care and population health services to support under-resourced communities. An emerging model of community paramedicine, mobile crisis management programs dispatch specially trained paramedics and EMTs to respond to behavioral health crisis situations.
- Co-responder Programs. Co-responder crisis intervention models pair law enforcement and behavioral health specialists to respond to individuals in behavioral health crises.
3. Which Populations Are Eligible to Receive Community Mobile Crisis Intervention Services?
Most crisis services, including mobile crisis intervention services, are geared toward treating adults ages 18 to 65. This means that crisis supports are often lacking for special populations, including youth, older people and individuals with co-occurring intellectual and developmental disabilities (I/DD) who experience behavioral health crises.
To address the growing behavioral health crisis needs of children and youth, states can consider designing youth-specific mobile crisis intervention models. Individuals with I/DD are more likely to be diagnosed with a mental disorder than other individuals, yet disability-specific crisis supports are often lacking for this population.6 A number of states cover behavioral health crisis services for Medicaid beneficiaries with I/DD and co-occurring mental health disorders who are receiving long-term services and supports (LTSS) through Medicaid waivers.
Today, there are also significant barriers for accessing culturally competent mobile crisis intervention and other crisis services for Black, Latino and LGBTQ populations.7 New ARP funding provides states the opportunity to design new or enhance existing community mobile crisis intervention services to be inclusive of the needs of these and other populations of focus.8
4. How Can States Use the New ARP Option and Funding to Support a “Firehouse Model” for Crisis Services?
Currently, funding for state and local crisis systems is pieced together across a patchwork of funding sources and payers. Funding is also largely inadequate to sustain the crisis system using a “firehouse model,” which refers to mobile crisis service providers who are “on call” and able to be dispatched at all times to anyone in crisis regardless of insurance status. Medicaid can reimburse for crisis services delivered to Medicaid-covered individuals only. Many private insurers may not cover crisis services. Taken together, these factors force states and localities to subsidize crisis services for insured and uninsured individuals using limited state and local funds, which inhibits the access and availability of mobile crisis services across states and localities.
The state option for qualifying community mobile crisis intervention services represents a promising opportunity for states to better leverage federal funds to sustain their crisis systems and crisis providers. States that have expanded Medicaid will be able to claim 90 percent federal matching funds to support mobile crisis intervention services. For all other Medicaid enrollees, states will be able to claim an 85 percent enhanced federal match on these services for the first three years of the option.
Conclusion
The ARP mobile crisis state option and enhanced federal matching rate provide a critical tool for states to invest in a more equitable, comprehensive and integrated crisis system that connects individuals in behavioral health crisis with specialized and appropriate behavioral health treatment. The ARP mobile crisis option and funding can jump-start states’ efforts to reform their crisis systems.
1. Public Law No: 117-2. March 11, 2021.
2. Scott, R. Evaluation of a Mobile Crisis Program: Effectiveness, Efficiency, and Consumer Satisfaction. Psychiatric Services. September 1, 2000.
3. Guo, S., Biegel, D., Johnsen, J. and Dyches, H. Assessing the Impact of Community-Based Mobile Crisis Services on Preventing Hospitalization. Psychiatric Services. February 2001.
4. Lowery, W., Kindy, K., Alexander, K., et al. Distraught People, Deadly Results. Washington Post. June 30, 2015. Available here.
5. Public Law No: 116-172. October 17, 2020.
6. Watson, A., Compton, M. and Pope, L. Crisis Response Services for People with Mental Illnesses or Intellectual and Developmental Disabilities: A Review of the Literature on Police-based and Other First Response Models. Vera Institute. October 2019. Available here.
7. National Association of State Mental Health Program Directors, Assessment #8, Crisis Services: Addressing Unique Needs of Diverse Populations. August 2020. Available here.
8. Ibid.