Hello, and welcome to today's webinar on Crisis Transformation, Now is the Time. This webinar is hosted jointly by the American Psychiatric Association, the National Association for State Mental Health Program Directors, or NASHPD, the American Foundation for Suicide Prevention, and the National Council for Mental Well-Being. I'm Dr. Stephanie O'Meal, and I'm the Director of Public Psychiatry Education at Columbia University and at the New York State Psychiatric Institute. I'm also a member of the American Psychiatric Association and a member of the Group for the Advancement of Psychiatry that just released a new report titled Roadmap to the Ideal Crisis System, and that's what we're going to be focusing on today. I'll be providing an overview of our report and moderating today's events. As you will hear from our speakers, we have a unique opportunity to implement changes that could drastically improve our nation's crisis system. A lot of work has already been done, but we still have a lot to do. For example, in 2009, I'm sorry, in 2019, the American Psychiatric Association worked with NASHPD to engage the mental health community in supporting increasing funds for crisis services. After a series of advocacy efforts, Congress established the Community Mental Health Services Block Grant set aside last year that appropriates $35 million in new funds for crisis care. With the set aside established, subsequent COVID relief funds through block grants provided an additional $115 million towards the development of crisis systems. This money will be allowed to be used over the next several years until 2025. In addition to these groups, in addition to these funding streams, there are other groups and many others who have been working with Congress and with the administration to pass a three-digit suicide prevention and crisis number, which is the 988 number, and we'll be hearing more about that during this webinar. Recognizing these unique opportunities, the National Council and the Group for the Advancement of Psychiatry assembled a group of experts together to identify what the ideal crisis system might look like. Given my work as the Director of Public Psychiatry Fellowship at Columbia, where all of our fellows work as psychiatrists in outpatient settings, and my advocacy work at the interface of the behavioral health care and the criminal justice system, I'm acutely aware of the limitations of our crisis care systems that we have now. Essentially, all we have is the 911 call, emergency rooms, and then people are either going to be hospitalized on an inpatient unit or they're going to be discharged back out to treatment as usual. It's not really a crisis system of care, but it's default 911 and emergency room care and inpatient care. I realize how important it is for us to really develop crisis systems of care. Now, I'll share with you some of the highlights from the report, Roadmap to the Ideal Crisis System. First slide. Just some housekeeping items. Physicians and clinicians can receive CME credit for this presentation, for this webinar, and we will have instructions on how to get that credit at the end of the webinar. Next slide. Next slide. Next slide. Thank you. This is the cover of the report. As mentioned, this report was put together by the Committee on Psychiatry and the Community, which is a subgroup of the Group for Advancement of Psychiatry. It really is a roadmap to help communities think about how to develop crisis systems of care. Next slide. What do we mean by the Ideal Behavioral Health Crisis System? It's really an organized set of collaborative systems, structures, processes, and services that are created to meet all types of urgent and emergent behavioral health crisis needs. The needs and the design of the system need to be reflective of the community that they serve and the populations that they serve. This needs to be done in an efficient and effective way. It's similar to the way we think about how we use the police in a community, or the fire department in a community, or emergency services in a community, and that the Ideal Behavioral Health Crisis System would be a part of that and would be handled in a similar way. As the picture here represents, we think about this as a pyramid. The ideal system is a pyramid. At the top of the pyramid is the person who's in crisis. This is the person that everything that we do needs to be focused on getting that person to the right level of care and getting their needs met and helping to dissipate the crisis or to address their crisis needs. If we look for this to work, you have to have a good foundation. The rest of the pyramid represents the foundation of the Ideal Crisis System. We start off with accountability and finance, because if you can't keep the doors open, the system won't work. We then move to services and the continuum of care. This is the array of services that people might need during a crisis or emergency. Then we have clinical practices. What's the actual treatment modalities that are going to be provided in this Ideal Behavioral Health System? We'll talk about this in each one of these different areas. Next slide. First, we'll start with, how do you read the report? It's a dense report, and it covers a lot of details. To start with, we start off looking at the values and operational principles. As the pyramid implies, all of the values and operational principles are based on a person-centered, recovery-oriented approach to care. Really what that is, is that we join with the person on top to try to get their needs met and help to empower them to be equal partners in how this journey plays out for them. We start off with those principles. We look at, then the report delineates design elements. Each one of the sections has specific design elements that are detailed. There are three major sections. The first section is about accountability and finance. That was the bottom of the pyramid. Then we have the crisis continuum, which was the middle part of the pyramid. Then we have the basic clinical principles, which is the treatment arm of the pyramid. The report also has essential components. As we go through each one of these sections, there are essential components that are spelled out in more detail. There are measurable criteria for each one of the different elements. There's performance measures that are recommended for each of the elements. In some cases, there are specific local examples of how these different elements have been actually implemented in different community settings. Next slide. We'll go a little bit more depth now in each section. Section one, the accountability and finance section. As I said, the only way to actually have a successful behavioral health crisis system is to have good and sustainable financing that can actually cover your costs for running the continuum and for running all of the services that make up the continuum of care. There needs to be accountability and quality improvement and performance evaluation in all of the different components of the crisis system. This comes under the responsibility of the accountable entity, or what we're calling the accountable entity. This is the entity that has oversight of all of these different components of the continuum. As we said, financing, eligibility, who are the payers, and who's going to be paying for the cost, and it may vary depending on what part of the system you're in, geographic locations, quality metrics, performance incentives, flow through front door and the back door to make sure that clients can move through and get to the level of care that they need. There's tracking. As people are moving through the system, we need to make sure that we know where they are, that there are assessments, that there's standard utilization management at each of the different levels, and that all of this is in relationship to the existing systems in any particular community. Next slide. Section two is the crisis continuum. Basically, this is all of the goods and services that are going to be included in the ideal crisis system. There needs to be a comprehensive array of services, that continuum of services, meaning that when a person moves from one level to the next, that it's seamless, that their information follows them, that their goals, their individual goals, and the behavioral health goals go with them, and that there's an adequately trained and multidisciplinary team of staff and support folks who actually hold all of this together and can help information flow from one team member to the next across all of the different systems that are involved in the overall crisis system. There are some essential elements to crisis care. I'm not going to go into detail on this, but the report goes into detail about each one of these different components. Having 24-hour access, having hotlines, having good triage and assessments of individuals' needs, having mobile teams and mobile crisis, having co-responders, either through 988 or through 911, but having coordinated co-responses, having crisis residences and drop-off sites and diversion sites. All of these can be part of the continuum of services. Next slide. Section 3 is the basic clinical practices. This is really the treatment that we're going to be providing. The Ideal Behavioral Health Crisis System has guidelines for utilization of best clinical practices and evidence-informed practices for crisis interventions. In addition to carrying out these services, we also have to keep track of practice improvements. As new types of treatment and more specialized treatment comes online, we have a way of keeping all of the workforce up to date with that and really understanding that our providers need to be well-versed in all of the different types of specialty care and treatment that can be provided in this continuum. Next slide. So then the report goes on to provide some helpful tools for the implementation of this. So the first steps really in the roadmap are 10 steps for communities. And basically, this is just helping communities to sort of think about where they are in terms of what already exists, where they want to be, and helping them to organize themselves and to make the decision that they want to actually implement an ideal crisis system. There are also 10 steps for systems leaders and advocates, because the providers can't do this alone, and that there are lots of stakeholders who need to be involved in sort of making this work successfully. And then there are six examples of successful crisis systems that have been implemented in other locations that can be used as models for any locality to sort of think about how they would like to implement it in their own area. And there's also a report card, which is really helpful. So as different localities decide to implement the ideal crisis systems, they can use the report card to sort of see where they are at any point in time and to sort of decide on next steps in terms of the continuous building and reorganizing of the ideal crisis system. Next slide. So we're including this certified community behavioral health centers because the model, both the financial model and the structural model of certified behavioral health centers is really ideal for thinking about designing a hub or the accountable entity for the ideal crisis system. And that's because the certified community behavioral health centers, CCBHCs, which is easier to say, already are required to have crisis outlines, 24-hour mobile crisis teams, crisis stabilization, and emergency crisis intervention. This is built into the model of the CCBHCs, and some of them also have emergency diversion, crisis stabilization and drop-in centers, and co-response with police and EMS. So they've already got the infrastructure and the fiscal enhanced billing opportunities that can really make the ideal behavioral health crisis system possible. Next slide. So these are some of the resources to some of the topics that I've discussed and also to the actual report, and we'll have this up again at the end of the presentation for you to have as a reference. Next slide. So now I'll introduce the presenters. So we will also, actually, before I introduce the presenters, I just want to say that we all have a role in developing better crisis systems, and we really hope that you will engage with us in this work and that you'll learn from our presenters today. And also we will have time for questions and answers after the presentations to help us put our heads together to really think about how can we create these unique, take advantage of this unique opportunity to really build the ideal behavioral health crisis centers. So now I'll introduce our speakers. Our first speaker is Bob Gebbia. Bob is the Chief Executive Officer of the American Foundation for Suicide Prevention, or AFSP. This is one of the leading suicide prevention not-for-profit organizations in the United States. Since joining AFSP, Bob has developed a nationwide network of more than 70 chapters and increased AFSP's annual revenues from $700,000 to over $39 million in support of this mission. He has an extensive background in not-for-profit management, strategic planning, fundraising, and in program development. Prior to joining AFSP, he had a successful career with the United Way and served as a public health advisor for the city of New York. Up after Bob, we have Dr. Debra Peinels, who is the Medical Director of Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services, and has consulted with the National Association for Mental Health Program Directors to support the development of reports on what states are doing related to crisis services. And then our final presenter is Kirs Merritt, who was one of our co-authors on the crisis report developed by the Group for the Advancement of Psychiatry, and she's also the co-director of S2I at the Jed Foundation. She was the Chief of Peer and Allied Health Professionals for the Los Angeles County Department of Mental Health. She also served as the Director of the Office of Consumer Affairs for the Center for Mental Health, CMHS, in the Substance Abuse and Mental Health Services Administration, SAMHSA, and also previously served as the President of the National Alliance for Mental Illness. So now we'll turn it over to our speakers, and Bob, you're up first. Well, thank you, Dr. Lumel, and thank you for sharing this comprehensive roadmap that truly will transform crisis services. So thank you. I'd like to talk a little bit about this, primarily from the advocacy point of view, and share some of the information how we got to this point with 988, some of the opportunities and challenges, as well as kind of where the advocacy is as of this moment. So if I can have the first slide, please. So how we respond to people in emotional distress really does matter. We all know that suicide continues to be a leading cause of death in our country. And there are over 10 million people who struggle with serious suicidal ideation every year. There's over a million people who act on that ideation and make an attempt. And we can do better. And even though we're encouraged by the fact that the suicide rate has shown a slight decrease starting in 2019, after two decades of going up, and that preliminary data for 2020 shows that it's slightly down again. That's coming from CDC. We're concerned about the long-term impact of COVID. We know that surveys have shown that there's increases in depression and anxiety, substance use increases in suicidal ideation, and particularly among young adults and in communities of color. So there's a lot we're concerned about going forward. But we also know suicide is a preventable cause of death if we invest in the prevention, the research, the education, the advocacy, and also if people get access to treatment. And that's where this crisis work is so important, because we also know that about half of those who have a mental health condition aren't in care. And often they are struggling, and they reach out through the crisis system. And it doesn't necessarily always end in positive results. So we need to do better. And I believe that if we think about crisis services as a part of the continuum of care and as a gateway to treatment, I think we can really reimagine it and do a better job going forward. So next slide, please. So there's a real opportunity to change crisis response. And it started really in 2018 when the passage of the Suicide Hotline Improvement Act took place in Congress. And it authorized the FCC and SAMHSA to produce a report to show the feasibility of a three-digit calling code for people in crisis, emotional crisis. That led to the passage in October of 2020 of the National Suicide Hotline Designation Act, which did name 988 as that three-digit calling code for people in emotional distress. And it will go live a year from now in July of 2022. So it's not live yet, and that's the target date for making it go live nationwide. But there are real questions and challenges here in terms of will the nation be ready? Will the infrastructure be in place to respond? There's questions about capacity to meet what everyone anticipates will be an increase in call volume, and some estimates show it could easily double in the first several years. So there's a capacity question, how can we respond? And second, what does effective response look like? And you heard some of that in the roadmap, but we need to do better and improve those outcomes when people do reach out for help through the crisis system. Next slide, please. So part of the advocacy is to increase federal funding for the National Suicide Prevention Lifeline. For those of you that may not know how that works, the lifeline, all calls coming through that system go through the lifeline, but then get channeled to local crisis services that are closest to the caller. So the lifeline is an entryway in, but the actual response takes place at a community level. So we wanna make sure the lifeline has the capacity to make that system effective, but also wanna make sure that the centers have the capacity, or we know calls will go unanswered, wait times could increase, and people won't get the help that they need. So the crisis centers around the country that are in the lifeline network, they really need to be adequately staffed, and they need more training to ensure both standards and quality, but also cultural competency. And we know that's a growing issue for many of them to keep up with that. So training and investing in that is as important as it is for the capacity itself. There's state legislation to help build that local capacity in some states, because one of the things that was real hidden gem in the national legislation was that it allows states to collect fees on phone bills to help support their local crisis services or the implementation of 988, if you will, just like that works with 911. And it's pennies in some cases, but it does help sustain 911 system. We believe the same thing can happen. And you'll hear more maybe about that from my colleague from Nashville, but there have been some state bills passed. There's some underway, and there's many, many more states that do not yet have any legislation to enact those fees. Next slide, please. There's more to re-imagining crisis response than that capacity in the call centers and the hotlines. And in a report that SAMHSA put out, it also calls for mobile crisis intervention, stabilization services as core components of an effective system. That exists in some places in the country, and there are models, as you've heard from Dr. Lamel, but it's certainly not extensive, and it's certainly not universal. We'd like to move towards that through our advocacy work, both at the federal and the state level. And I will tell you that there's been a pretty good response so far in Congress. The president's budget does include an increase to the lifeline, gets their funding up to $100 million from 24 million in its current budget. And in the appropriations in the House in that bill, it is a little higher, I think 114 million, but there is not yet a companion bill in the Senate, and we are working with many of our partners and colleagues to try to get legislation introduced there that would also allow for that funding to the lifeline system, and also funding for a public service campaign to let people know about 988. And that's an important investment we have to make too. Next slide, please. So when we think about crisis response, the current system, as you well know, is built around often law enforcement. They're the only ones available, and certainly when 911 is called. And often, and we've worked with many of the law enforcement agencies and their national groups, and they know they're not trained for these types of emergencies. So often they are the only ones available, and yet they don't have the training. Often individuals in distress, the only place to bring them is emergency rooms where they could wait for hours or even days without any mental health care. And often they can be, again, follow up, sent out to follow up, but that doesn't often happen. And there's a break in that continuity of care. The healthcare system loses connection with them, perhaps until the next crisis. So there is that. And then there are those who are admitted to hospital for care that they may not need or may not meet their needs. So there's things that are not working optimally that we need to fix. Next slide, please. Next slide. Next slide. Next slide. We seem to be having a little technical difficulty, and hopefully we'll get the slides back up in just a minute. Okay. Ah, there we go. So I'll try to pick up where I left off here, but I think that in reality, we know that we need to use mobile crisis, have more of a mental health response, maybe with law enforcement in some models, maybe without law enforcement, more follow up for those who come in contact with the crisis system, and really divert from efforts that really do not ensure safety or treat the underlying mental health conditions or suicidality. Next slide, please. There was a report by NASHPD and SAMHSA that we think really sums this up nicely and shows the promise of 988 and a reimagined system. By enhancing crisis response, lives can be saved with services that reduce suicides and opioid-related deaths, divert individuals from incarceration and unnecessary hospitalization, and accurately assess, stabilize, and refer individuals with mental health challenges. We think this statement really does capture what we need to work towards in our advocacy, both at the state and federal level. Next slide, please. So I would just end by saying, we have an opportunity to really change crisis response. It centers around 988, but it is more than just 988. And we must find ways to ensure that people who come through that crisis door, that gateway, get the mental health treatment that they need. And we must make these investments. On the scheme of things, it actually will save costs, but more importantly, we believe it will save lives. So thank you. I look forward to your questions when we get into the Q&A session. Thank you. And now I am gonna turn it over to Debra Pinnells from NASHPD. Great, thank you very much. Really appreciate it. And this is really an exciting time. I mean, there's not a day that goes by where my conversations aren't related to something about crisis services. And what I'm gonna be talking about is the perspective at the state level on building the continuum of care beyond COVID-19 and looking at what we were heading towards before COVID-19. Next slide. So I hold a couple of roles. Just wanna point out that one of them is as the chair of the medical directors division of the National Association for State Mental Health Program Directors. And that's how I'll be speaking from that state level perspective. And although I do consult to other jurisdictions, I have no financial conflicts relevant to this topic. Next slide. So what is the National Association of State Mental Health Program Directors? It is actually the organization that is working closely with the American Psychiatric Association and the American Foundation for Suicide Prevention and others. And what NASHPD as we fondly call ourselves is known for is representing the over $41 billion of public mental health systems serving 7.5 million people annually in all 50 states, four territories and the District of Columbia. And NASHPD relates to the state psychiatric hospitals around the world. It relates to the state psychiatric hospitals around the country, which has and support 147,000 people per year at last count and almost 42,000 people at any one point in time. And so essentially it's the state mental health authorities across the United States and the territories. Next slide. NASHPD has a mission to work with states, federal partners and stakeholders to promote wellness, recovery and resiliency for individuals with mental health conditions or co-occurring mental health and substance use related conditions across all ages and cultural groups. And so there's a child division, there's an older adult division, there's a focus on forensic issues, people caught in the criminal or juvenile system and many other divisions that we have that really help state mental health authorities look at how to support access to a full continuum of services across settings. Next slide. Of course, in having that as the mission, there are several values that are upheld and that includes the least restrictive and most integrated settings in human rights and health equity, health and wellness, recovery and person-centered services and planning and the unique role of safety net services in the public mental health system that continue to this day. And more recently, there's many things that NASHPD has embraced including zero suicide, working collaboratively around some of these efforts around crisis services, looking at how do we think about the workforce and culturally and linguistically responsive services. And all of these values and strategic plan items kind of coalesce into this crisis services build out conversation. Next slide. So in 2017, NASHPD produced on behalf of SAMHSA, a paper that I was fortunate enough to be asked to write, which was called Beyond Beds, the Vital Role of a Full Continuum of Psychiatric Care. And this theme of Beyond Beds came about when there was a lot of media push around building up psychiatric hospitals as a single solution to all of the challenges in the behavioral health system. And very often that attention from media was focused on state psychiatric hospitals. However, we've come a long way from that as a single solution. It doesn't mean that we don't need to look at psychiatric beds, because of course psychiatric inpatient level of care is a necessary component of care. But what became clear is that what we really need is a much more robust continuum of psychiatric care that provides all levels of care just like we see in medical services. And so the 2017 recommendation said, states, this is the time policymakers really think about how to build out that vital continuum. Let's get our terminology straight around what we're talking about. Think about jail diversion strategies and juvenile justice diversion. What's happening in emergency treatment practices? What is happening in the psychiatric bed availability for inpatient services? How do we look at data? How do we build out linkages? How do we utilize technology, build a workforce and enhance partnerships including non-traditional partnerships to enhance the behavioral health system? Next slide. And before just as COVID-19, it wasn't actually before, we had the rollout of the national guidelines for behavioral health crisis care best practice toolkit from SAMHSA, which essentially is some of the work that we're still resting on today. And that was mentioned in the prior discussion about the GAP report. And this was produced and published in February of 2020 already so long ago, given all that we've been through but no less relevant today than it was when it was pushed out to the public. Next slide. Next slide. Then we saw COVID-19 that came quickly and furiously and has required states to really pivot dramatically. And what we've seen is a lot of things related disaster planning in an unprecedented and demanding way with clinical shifts and demands that has required partnerships across many federal entities with the states together trying to drive the response to COVID-19 which I think has taught us a lot about what we're gonna need to do further in the crisis space. Next slide. So in the crisis space with COVID-19, we've already been standing up crisis call lines. The disaster distress helpline received a number of major increasing calls across the country. Many states have developed crisis counseling program grants through federal dollars to help support the community dealing with the distress related to COVID-19. But it's also forced us to look at mobile crisis and how that's gonna work and crisis stabilization, short-term crisis residential, and all being impacted because of COVID-19 with expanded use of video visits and tele-visits when feasible and clinically appropriate, as well as looking at who's got certain physical health symptoms that for example, might be associated with COVID-19, which is I think taught us a lot more about integrated care and services that will need to continue to be rolled out with this crisis care best practices toolkit. Next slide. There was also other momentum that was going on prior at the state level, prior to COVID-19 that informed this. So we've heard a lot about suicide prevention in 988 as a major driver for the current push for crisis services. However, there are other drivers that the states are putting a lot of energy into. And one of those includes jail diversion. I think almost it's not every state in the country right now has something going on either at the county level or at the state level, really focusing on this problem of people with serious mental illness and substance use disorders being overrepresented in the criminal legal system and in the juvenile system. And so many efforts have been put in in a bipartisan way to look at alternatives to incarceration, alternatives to arrest. And this is before the whole defund police movement. Of course, we've heard about suicide prevention. So I won't say more except for the fact that the states are very aware of that and the state mental health authorities have a role to play in that for both the public mental health recipient as well as the non-public mental health recipients since they are the mental health authorities for the state and are required to look at the mental wellbeing of state residents. There's also the ED boarding challenges that we know exist with people waiting far too long for access to inpatient services, the opioid crisis which we saw some improvements in in some regions, but with COVID-19 are now seeing those numbers climb back up again. The enhancement of mobile crisis services was happening before COVID-19. Again, it's only gonna be enhanced further with the federal dollars that are coming down and with some of the things that are rolling out around for example, children's behavioral health services where several states are facing litigation and moving forward with building out mobile crisis services and supports to enhance access to immediate care. Next slide. And as was mentioned after the best practices toolkit came out SAMHSA worked with the National Association of State Mental Health Program Directors to develop technical assistance papers and 11 papers were produced last year talking about realizing 988 and looking at crisis services in this compendium that became known as crisis services, meeting needs, saving lives. And again, I was fortunate enough to be able to have the opportunity to write some of these papers but these papers really focus on looking at the law enforcement mental health interface. They focus on rural versus urban issues and challenges. They focus on technology enhancing the capabilities of peer support what's happening with children's services how to expand diverse access to services for diverse populations so that they serve all who come into them. And now using some of these this work of the crisis services meeting needs, saving lives effort SAMHSA is continuing to drive some response of the states as it looks at block grant dollars which have set aside amounts to expand the capabilities of crisis services. And just recently SAMHSA requested states to produce a sort of a broad picture of what was happening, how sort of the readiness of the state and the readiness of the counties along a variety of dimensions in terms of building out the crisis services so that there's a place to begin. We also have the American Rescue Plan funding that every state is starting to talk about in terms of how that will be rolled out and available to members of each state. And furthermore, the state leaders are working hard to develop partnerships to expand the crisis continuum even further including those non-traditional partnerships. So the work is happening at the state level at a fast and rapid pace. Next slide. There's also a lot of emphasis looking at trauma-informed practices equal access to all in terms of diversity, equity and inclusion and then policies, practices and principles required to eliminate disparities. We saw with COVID-19 the disparities and impact of the infection and we know that there's disparities in mental health services. And so there's a lot of intentional effort to look at these crisis services and make them user-friendly across all populations. And that's gonna take a lot of work as we roll forward. And it's going to take a lot of work across disciplines as well, including psychiatrists and other mental health professionals who need to be able to do proper assessments and ensure that there is just an equal access of crisis services to all. Next slide. Partners really are broadening. There is a lot of work being done with Vibrant Emotional Health and the National Suicide Prevention Lifeline in partnership with RI International and the National Association of State Mental Health Program Directors. They convened a series of four two and a half hour working sessions over the course of December of 2020. And now there's even a weekly 988 learning collaborative what they call the crisis jam, where leaders from around the country get together. I think there's about 250 participants at this point, listening in, getting information and feeding it back to their constituents across the states. Next slide. A lot of work happening in the regulatory policy and program advances. I can tell you in Michigan alone, we're working on this area, but every state is looking at statutes and regulations, how the funding is going to work, as you've heard about before, and then the very real issues related to workforce, since we know that we have some workforce challenges ahead. Next slide. And with that, I'll stop, and I hope there's opportunity for question and answer afterwards, and I'll turn this over to Karis. Hi. Thank you so much. Thank you to the previous presenters. I'm going to pick up talking about the roadmap and specifically the essential element of peer support. I'm sure a lot of you already know from probably previous presentations or maybe your work that a peer support is a person with lived experience with a mental health or substance use condition who helps another person on their road to recovery. I'll talk a little bit about what peers do and some evidence of the outcomes, especially when it relates to pre, during, and post-crisis. Next slide. So I wanted to start here that in the GAP report, that's my really wicked way of circling something that was essential in the GAP report, but in the GAP report in one of the sections, it talks about the practice guidelines for interventions and treatment, and I'll call out the box there that specifically talks about crisis system and each crisis provider incorporates peer support into interdisciplinary teams. So of course, with any team member, you want to define the role of peers and what kind of expertise they have, especially as it relates to their core competencies and practice guidelines around hope, engagement, connecting to resources, et cetera. So next slide. I think it's also important to remember, of course, that, you know, if you think about it, when somebody's in crisis, how helpful it is to have somebody else who's been through something similar, but made their way out of it, be able to support you through. So it doesn't seem like this foreign concept, but one that, wow, like somebody else has been through it. There was a person with lived experience when I first went through my crisis, which there were several of them. Many times I thought, well, nobody could possibly understand even my providers. They've never been through anything like this before, but when being able to talk to a peer alongside the provider helps be able to see that the possibility of being able to move forward in one's recovery. So this is a rather old document, but I kind of like it when we're thinking about interdisciplinary teams. This kind of, this was done with NAMI in a circle of care guidebook. And the really kind of cool thing about it is that it helps anybody kind of understand the different roles of the different provider types that they might be encountering no matter where they are in a different treatment and or support settings. But it helps, especially when you're integrating a peer into an interdisciplinary team, it can help the peer understand the role of the other folks on the team and people on the interdisciplinary team understanding the role of the peer. Not that one has to use this particular template, but certainly one could create a template of their own. Next slide. So this gives another example when folks are considering the role of a peer in a crisis system. So in the whole system, when you look at the gap report and look at the self-assessment or the report card in it, it will ask, you know, have you incorporated peers? And this might be one way to think about, well, I could check the box. Yes or no. I kind of want to do it a little bit better. The question is where and how does one want to incorporate peers within the system or the continuum within the system? So you can see, for example, on the very far left side, it talks about the different types of services and supports. And then in the middle, it talks about the settings. And then on the right, it talks about what populations might be in those settings, for example. So if we think about crisis or pre-crisis, it might be, well, how are folks helping with housing, housing services and supports and connecting people to that through street outreach? How are people, again, people think transportation, well, a peer doesn't want to do transportation, but actually there are roles to support people with transportation and while you're transporting that person to be able to connect with them about what's going on in their life. Generally on mobile crisis teams, however, where you might be going out to do some outreach with a person who is in crisis, we discourage from having the peer be the driver in that case, but rather the person who can be used on that team while you're driving maybe to a resource, to a community mental health center, et cetera, that the peer supporter actually be able to connect with the passenger who is the person in crisis. So it's kind of hard to do that while they're also driving the car. So we discourage that, but you can see the different areas in which peers are involved. The other and the different types of support. The other thing to think about is in the SAMHSA core competencies for peer workers, which is the first integrated set of core competencies for peers and substance use, mental health, family members, people with lived experience and use. So it's kind of all one set of core competencies for these types of peer providers. In it, there is a section around a competency around supporting peers in crisis. There's also a section about participating on interdisciplinary teams. So this is a part of what should be in folks training. When I talk about peers having specialized training, those trainings generally align with either the SAMHSA core competencies or core competencies that have been adapted by other states. There are 48 states now with certified peer specialists. Many of those states do reimburse Medicaid. There is a Medicare bill now, the Peers in Medicare Act, which is a bipartisan act of Judy Chu and Adrian Smith that actually clarifies the role of reimbursing peers within Medicare as well. Next slide. So the other thing that can be in a continuum of care, especially around crisis and crisis support is peer respite. Now, these aren't all over the United States yet. They're cropping up in pockets. As a matter of fact, in Oregon, they recently passed a bill, the governor signed a bill to fund for peer respites in the state of Oregon where they didn't have any. So that is kind of an indication about what's happening with peer respites. A peer respite is a place where somebody can go either pre-crisis or if it's a crisis that does not need medical attention to get 24-hour support in a short-term overnight program. So usually there's community-based non-clinical crisis support to help people find, kind of understand what's happening and also to help them move forward. Some of the peer respites also have family supporters to be able to support the family member whose loved one may be staying at the peer respite. They do operate 24 hours a day. They are not long-term. Usually most people stay less than a week. Some have rules that you can't stay more than 14 days, etc. It depends on the particular peer respite. So they are operated by people who have psychiatric histories or people who also have experienced trauma. So sometimes that can be while people are waiting for, well, you know, where am I going to go when I'm in crisis and you can't get into the ER, you can't get into a more traditional, if you will, crisis program, sometimes peer respite may be actually a nice place for people to resolve some of the crisis that they're going through, again, if they do not need direct medical attention at the time. Next slide. So there has been some research done on peer respites over the past couple of years and you can actually find some of the studies here at peerrespite.com. But so peer respite guests are 70% less likely to use inpatient or emergency services. And of course there's a less cost associated with that. So we also see that people feel more empowered and moving towards their own healing and having satisfaction with the services. And then also increases in self-esteem as well as self-rated mental health systems and social activity. Next slide. If you have interest in, again, sort of the greater value of peer support and what peer supports have the ability to do, when you look at the evidence, you can access these info briefs that were done at SAMHSA, I believe in about 2017, maybe 2018. There are four of them. There's an overall one for all peer support. There's one for peer support for people in recovery from mental health conditions, one for peer support for people recovering in substance use conditions, and then one for family parent and caregiver support. Next slide. So if we look at one of these, you can get an idea. They're really easy to use. We made them kind of two-sided. It defines exactly what a peer supporter is. It defines what a peer support worker does. And then on the back side, next slide, it actually will give a listing of some of the outcomes from evidence. A lot of times when states were trying to figure out or localities, what are they going to do with peer support? What value do they have? They would come to SAMHSA and ask to help them with literature reviews. And so we just made these easy infographics and kind of condensed all of the information into one area. The other thing I think is really important, and we're still gathering evidence on this as well, is having peer supports help with things like psychiatric advance directives. That can also be super helpful for people when they're in crisis or pre-crisis or even post-crisis so that people can think about what is their plan and put that plan into a psychiatric advance directive. The same thing can be also with wellness recovery action plans, which there is a lot of evidence. It is an evidence-based practice for peer supporters to provide support to people with wellness recovery action plan, which again helps people break down what is your life like, like no crisis? What is it like when it's getting a little rocky? What is it like when you are in crisis? And what is it like post-crisis? And then come up with your plan for each stop along the way to hopefully negate or reduce getting all the way into crisis. So those are other practices that peers can do to support people they're working with pre, during, and post-crisis. Next slide. I'm trying to move the slides. I cannot do that. Okay, so I think that's all I'm going to talk about to make sure that we have time for Q&A. And just, I love this quote because I think, you know, when we're in crisis and we put together a team and we're all working well together, then that really helps us turn illness into wellness. Thank you. Terrific, everyone. First, I just want to thank our speakers for their wonderful insights and helpful presentations. And as we, as you've heard, a lot of work is going into thinking about the ideal crisis system. We've heard about 988 and how it's contributing to the continuum. We've heard about what the states are doing in terms of targeting different aspects of the continuum of care and also the impact that COVID has had and social justice and how that fits into our ideas about the ideal crisis system. And we've heard about peers and about the use of peers. And I'll just add that I think we focus a lot on peer education and peer training, but I think it is just as important that we train our multidisciplinary teams to really understand the value and expertise that peers bring. And that is a bi-directional learning that has to happen for us to truly incorporate peers in a meaningful way into our different systems. And the crisis system is a perfect place for that. So now we'll open it up to questions. And I think there were a couple of questions that came in. I'll start with this one. And I guess this is probably for Rob. With the 988 number, is there a way to better coordinate care for a person in crisis with their psychiatrist? Specifically that oftentimes when people end up in an emergency room, their clinicians, their psychiatrists are not informed of where they are. So will the 988 system help us to try and make that information available? Again, I think that's a great question. And I think it comes down again to the kind of training that our crisis center team members get to be probing that, to asking about, are you in care? Asking about who their provider is and making those linkages. And also when you follow up, have you seen your provider? I mean, there's those kinds of ways. I also think stabilization centers can do a better job of making those linkages than emergency medical rooms. Because the kind of intensity we've all been to, ERs, we know how wild it can be and triage. And it falls to the bottom, I think, too often to ask those kinds of questions. I think in a well-trained stabilization center, you can make those linkages and make that happen as part of the development and training of those centers. Okay. There's another question that came in about NAMI and about NAMI's involvement in the development of crisis systems. That's open to anyone who wants to chime in on that. They're super involved. I would say they're super involved at the state level, too. They're super involved at the national level. Angela Kimball, who is the head of their policy, I forget what her whole title is, actually does have a weekly call as well with a number of groups to look at the 988 legislation and also to guide in that way. So I think it's a... And I'm thinking also they're involved with the RI work. So, yeah. Okay. There's another question about opportunities for receiving grants or support for establishing peer respite services. Do we have any links to those or organizations to contact? Wow, and I wish. Then we would probably have one or more in every single state rather than just a few throughout the country. So I think a good idea is to look at Oregon as an example. Their bill was HB 2980 to actually see what that bill looks like as far as how it was constructed and how the peer respites are supported. You can go to peerrespite.com, which is the link that was on my slide about the outcomes of peer respites to look at other mechanisms to stand up and what does it take to fund a peer respite as a start. Right. And we'll have... Everyone who's participated today will have access to the links that have been discussed. We'll have that available. So- Yeah, I can add to that. There are some funds, at least in the house version of appropriations for, in addition to the block grant monies that have set aside for crisis, there now is some money earmarked for pilot grants. And that's pretty loosely defined how they could be used. So that might be an opportunity to advocate for that question about peer respite centers. That's something we'll look at. And the other thing just to say is that many states do reimburse for peer services, and there's more and more states that are doing that. And so that's something important to realize for your own state as also another piece, even if it's not a peer respite, just peer support services themselves can be Medicaid reimbursable. Absolutely. And that's an advocacy point as well, that it's important for us to lobby for that, to get more states to reimburse for peer services. And also on the substance use side too. So there are fewer states that reimburse on the Medicaid side for substance use recovery coaches, which are peers on the substance use side, but they're more for Medicare. So it's very interesting, but it does mean it's an advocacy point of contact for all of us. Right. So unfortunately we're out of time, but obviously there's a lot more to be done. There are more questions to be asked. And again, I just want to thank our presenters for this. And I encourage you all to take a look at the roadmap and to use the tools that are in the roadmap to think about your localities, get in touch with us, all of us here who can help you in the various areas of our expertise, but to really think about how you can try to really create a crisis system of care in your locality. And thank you all for joining us today. Take care.

crisis transformation

ideal crisis system

American Psychiatric Association

National Association for State Mental Health Program Directors

funding for crisis services

three-digit suicide prevention and crisis number

peer support

coordination of care

limited resources

advocacy for ideal crisis system