ColoradoCrisisSteeringCommittee

FinalReportand Recommendations

PreparedbySHGAdvisorsJune2018

TheColoradoCrisisSteeringCommittee

TheColoradoCrisisSteeringCommitteeisagroupofdiversestakeholderswhoworkedtogethertoproviderecommendationstotheColoradoDepartmentofHumanServices(CDHS)onhowtoimproveandenhancetheState’sbehavioralhealthcrisissystem.TheCommitteemettoidentifygapsincurrentservicedelivery,aswellasopportunitiestoincreasesystemefficienciesthatwillimproveresponseinallcommunitiesandreachthosepopulationsathighestrisk.Additionally,theCommitteesoughttounderstandhowdatacouldbebetterusedtodemonstratetheeffectivenessofthesystem.

Thisdocumentistheresultofthecombinedeffortsoftheindividualslistedbelowandthestakeholdersandcontentexpertswhosharedtheirinsights,knowledge,andperspectivestoadvancetheCommittee’swork.

TheresaAnselmoColoradoAssociationofLocalPublicHealthOfficials

TomBarrettMentalHealthColorado

AubreyBoggsColoradoMentalWellnessNetwork

JasonDeaBuenoSouthernColoradoCrisisConnection

RickDoucet CommunityCrisisConnection

JoshuaEwingColoradoHospitalAssociation

GretchenHammerDepartmentofHealthCarePolicy&Finance

CamilleHardingColoradoDepartmentofHumanServicesOfficeofBehavioralHealth

JarrodHindmanColoradoDepartmentofPublicHealth&Environment

CheriJahnStateSenator

TracyKraft-TharpStateRepresentative

LoisLandgrafStateRepresentative

BevMarquezRockyMountainCrisisPartners

MichaelMcIntoshCountySheriffsofColoradoAssociation

DafnaMichaelsonJenetStateRepresentative

JerenePetersenColoradoDepartmentofHumanServices

LarryPottorffNortheastBehavioralHealth

ShellySpauldingWestSlopeCASA

SarahVaineSummitCountyGovernmentDepartmentofHumanServices

RobertWerthwein,CommitteeChairColoradoDepartmentofHumanServicesOfficeofBehavioralHealth

TonyaWheelerAdvocatesforRecovery

Specialthanksto:MicheleLueckandEmilyJohnsonoftheColoradoHealthInstitutefortheirdataanalysisandrecommendations.

ColoradoCrisisServicesEstablishedin2014,ColoradoCrisisServicesispartoftheState’s“StrengtheningColorado’sMentalHealthSystem:APlantoSafeguardAllColoradans.”ItisaninitiativechampionedbyGovernorHickenlooper,andisthefirststatewideresourceformentalhealth,substanceabuseoremotionalcrisishelp,informationandreferrals.Itspurposeistoprovidegreateraccesstomentalhealthservices,ensuringColoradansgettherightservicesintherightlocationsattherighttime.Thesystempromotesaccesstothemostappropriatesupportsandresourcesasearlyaspossibletodecreasetheutilizationofhospitalemergencydepartments,jails,prisonsandhomelessprogramsforbehavioralhealthemergencies.Thissystemisrevolutionary,and,initsinfancy,hasalreadytransformedcrisisservicesinColorado.Yet,therearestillchallengestoacknowledgeandimprovementstobemade.Ultimately,itwillreflectacontinuumofcarefromcrisisresponsethroughstabilizationandsafereturntothecommunitywithadequatesupportfortransitionstoeachstage.Thecrisissystemisstrivingtomakeaculturalshift,andthosetypesofevolutions–andtheirimpacts–taketime.

ColoradoCrisisServicescurrentlyconsistsoffivemodalities:(1) StatewideHotline.Thestatewidecrisishotlineisa24/7,year-round,community-basedsystemofcrisisintervention

servicesfromwhichpeopleexperiencingmentalhealthand/orsubstanceabusecrisiscanbesafelyandeffectivelystabilizedandefficientlylinkedtoappropriatefollow-upcareandservices.

(2) MobileServices.MobileServicesrespondtowheretheclientis,within1hourinurbanareasand2hoursinruralareas.

Itisstatewideandavailable24/7/365.MobileServicesworkscollaborativelywithtelephonecrisisservices,walk-inservices,crisisstabilizationunitsandcrisisresidential-andcommunity-basedservices.MobileServicesworkscloselywithlawenforcement,schoolsandhospitalemergencydepartments.

(3) Walk-InCenters.Atthewritingofthisreport(June2018),thereare12Walk-InCentersacrosstheState.Walk-In

Centersareopen24/7andofferconfidential,in-personassistance.Servicesareprovidedtocustomerswithin1hourofarrivaltime,andcustomerscanstayforupto23hours.ThefocusofWalk-InCentersincludesintervention,education,connectingtocommunityresourcesandreferralstohigherlevelsofcare(ifapplicable).

(4) CrisisStabilizationUnits.CrisisStabilizationUnits(CSUs)provideonsitetherapyforuptofivedays.Thesupportmaybe

intheformofone-on-onecounseling,grouptherapy,medicationmanagement,oracombinationofallservices.CSUsareavailableforinvoluntaryandvoluntaryadmissions.Afterstabilizingthecrisis,therapistsintheunitworkwiththepatienttocreatealong-termtreatmentplanandhelpthemreintegratebackintothecommunity.AcrossColorado,thereare107CSUbedsavailableasofJune2018.

(5) Respite.Respitecareservicesprovidetherapymanagement,medicationmanagementandin-patientmentalhealth

treatmentforupto14days.Colorado’smentalhealthcrisissystemhastwotypesofrespiteservices,oneforadultsandanotherforchildrenandadolescents.Adultrespiteservicesconnectpatientstodesignatedbedsinthecommunity,wheretheycanremainforupto14days.Respitecarelocationsoffercounseling,medicationmanagement,andsupportforfamiliesandcaregivers.Respiteservicesareavailableforvoluntaryadmissionsonly.

CommitteePurposeTheColoradoCrisisSteeringCommitteewasformedinearly2018to:

• Identifygapsincurrentservicedeliveryoraccess.• Addresstheuseofdatatodemonstratetheeffectivenessofthesystem.• Increasesystemefficienciesforcrisisservicesandimprovemobileresponseincommunities.• Establishservicesandclinicalstandardstomeettheneedsoftheintendedpopulation.• Ensurethatservicesarereachingthosepopulationsathighestriskofsuicideincludingadolescents,adultmenand

veterans.• Addresslicensingchallengesandprioritizeregionalsolutionsforco-locatedandfullyintegratedservices.

TheCommitteeistaskedwithdescribingtherecommendationsitwouldliketoseeimplemented.OBHwilldeterminethe“when”andthe“how.”ProcessTheSteeringCommitteemeteighttimesbetweenMarchandJune2018.Allmeetingswereopentothepublic,withobserversinattendance,andincludedopportunitiesforpublicinput.SHGAdvisors,alocalconsultingfirm,facilitatedanddocumentedtheprocess.

Overthethirteen-weekperiodduringwhichitmet,theSteeringCommitteespenttimeunderstandinghowthecurrentsystemisfunctioning.TwosurveysweredisseminatedacrosstheState:onetosolicitinputfromstakeholders,especiallythoseinruralareas;andanothersurveytosolicitinputfromconsumers(orfamily/friendsofconsumers)whohaveusedthecrisissystem.Twosub-groupsformed(oneforthehotline&MobileServices;andtheotherforwalk-incenters,crisisstabilizationunitsandrespite)toidentifyprioritizedrecommendations.Theserecommendationswerepresentedatanall-dayworkshoponMay18th,atwhichtimeCommitteemembersinformallyvotedontherecommendationstheymostsupported.TheserecommendationswerecompiledanddistributedtothefullCommitteeforanelectronicvote.(SeeAppendixB:SummaryofTaskForceMeetingAgendasandPresentations.SeetheCDHSCrisisSystemExecutiveSteeringCommitteewebsiteformeetingagendas,presentations,minutes,andrelatedmaterials.)

Initsfirstmeeting,theCommitteediscussedandagreeduponthefollowingmechanismtomakedecisionsgoingforward:

• Uponvoting,themajorityvotewins.o IfaCommitteemember(s)votesintheminority,theyhavetheoptiontowriteandsubmita

summaryoftheiropinion.o TheCommitteewillvoteontheminorityreporttoensurethatitaccuratelyreflectsthe

conversationwhenthevotetookplace.Ifvotedintheaffirmative,theminorityreportwillbeincludedinthefinalreportsubmittedtotheCDHSDirector.

OnJune15,2018,theSteeringCommitteeapprovedtherecommendationssharedinthisreport.

RecommendationsTheCrisisSteeringCommitteeembracedtheideaof“NoWrongDoor.”Inotherwords,ifapersonisinneedofcrisisservices,theyshouldbeabletoaccessservicesusinganyofthemodalitiesavailablethroughthecrisissystem.Thecrisissystemaimstoprovidetherightservices,intherightlocations,attherighttime.Itshouldbeaflexible,integratedsystemthatmeetsthecommunityneedsandacknowledgeseachcommunity’snuances.Giventheever-changingenvironmentinwhichwelive,thesystemshouldremaincurrentandrelevant.AcknowledgingthatthecrisissystemneedstoprovidegreateraccesstomentalhealthservicestoensureColoradansgettherightservicesintherightlocationsattherighttime,theserecommendationsweresupportedbythemajorityofCommitteememberswhovoted:

RecommendationOne:Increasethebreadthanddepthofservicesforyouthandchildren.ThereareanumberofstepsthatCDHScantaketoensurethatyouthandchildrenhaveaccesstobehavioralhealthservices:

• Launchatargetedmarketingcampaign.ReviewtheresultsfromthepilotconductedinColoradoSprings(targetedat10-16-yearolds)and,ifsuccessful,considerscaling.

• YouthMentalHealthFirstAid(YMHFA).ExpandYMHFAtrainingtoparents,familymembers,caregivers,teachers,schoolstaff,andpeers.InstructpartnersthatanyState-sponsoredorState-fundedactivity/initiativeinwhichyouthparticipaterequiresthattheColoradoCrisisHotlinenumberisaddedtotheyouth’scellphone.

• Increasebedcapacity.Increaseoptionsforyouthwithsubstanceusedisorders,eitherasrespiteorlonger-termplacement.Improveresidentialtreatmentcapacity.ThiscouldimprovegivenMedicaid’srecenteffortstoobtainawaivertoprovideinpatientandresidentialsubstanceusedisordertreatment.

• Increaserespitecapacity.Inthelastlegislativesession,thefinancecommitteeapprovedanincreaseinmoneyforin-homerespite.Ensurethatthisisbeingusedeffectively.

• Offertwo-waytextingcapacity.Thistechnologyoffersaconversationalnatureoftexting,andenhancestheSMSconversationbyactivelyengagingyouth.Youthcouldindicateiftheyare“okay”ornot.Dependingontheresponse,theyouthwouldbeconnectedtoa“live”person.

RecommendationTwo:Increasepeersupportinallareas.Peersupportspecialists(PSS)arepeoplelivinginrecoverywithmentalhealthconditionsand/orsubstanceusedisorderswhohavebeentrained,basedoncorecompetencies.Peersupportworkswhenindividualsaretrainedandhavepropersupervisionandsupport.Peer-runservicesarenottrulypeer-rununlesspeersareinvolved–trulyinvolved–everysinglestepofthewayinbuildingthoseservices.ThereareseveralstepsthatCDHScantaketoeffectivelyincreasePSS:

• Definetrainingstandards(modelsforthisexist)forPSS.InColorado,peersarecurrentlymadePSSbymanydifferentstandards.TheidealstandardforaPSStrainingprogramisonebasedoffoffeedbackfromthepeercommunity.Peoplewithlivedexperienceshouldbetheonescreatinganddefiningwhatthattraininglookslike.

• Addressandensureappropriateandsupportivesupervision.EstablishstandardsforpeersupervisionsothatPSSwillavoidburnoutmoreeasily.Considerusingthe5PillarsofPeerSupportSupervision.

• Offerpeerrespite.Peerrespitesaremostoftenovernight/short-termprogramsthatarecompletelyvoluntary.Peerrespiteshaveastaffandleadershipthatare100%peoplewithlivedexperienceofmentalhealthconditionsand/orsubstanceusedisorders,thebehavioralhealthsystem,and/orcrisissystemexperience,oratleastthatthemajorityofthestaffhavelivedexperience.Peerrespitesoftenvaryinservices,policies,size,andmore,buttheonethingthatiscommonacrosspeerrespiteisthattheyarevoluntary,recovery-focused,trauma-informed,andarerunandoperatedbythepeercommunity.

RecommendationThree:Leveragetechnologytoconnectandsimplifythestateandlocalcrisislines.TherearetwooptionsthatCDHScouldexploreunderthisrecommendation:

• CreateaGPS-enabledappthatpeoplecanusetofindthecrisisresourcesclosesttothem.Thisoptionoffersalocal-andregional-basedface-to-faceservicechoiceatpointofaccess.Thisoptioncouldincludetheabilitytotalktoacounseloronthetelephoneviathestateorlocalagencycallline.Thestatehotlinecouldusethesametechnologytotriagetothelocal/regional-basedface-to-faceoption.ItwouldbebeneficialforallpartiestohavesharedElectronicHealthRecordssothatclientscanbetracked,medicalhistoriesareaccessible,andresponsesareconsistentthroughoutthecrisissystem.

• MaintainastatewidehotlineintheColoradoCrisisServicesprogramandcreateanappforcustomerstoaccessthehotline/text/peersupportlineandnavigateColoradoCrisisServicesasaprogram(anappnamecouldbeeasiertorememberthanaphonenumber).Thestatehotline

couldalsousethetechnologytolocatein-the-momentwalk-incapacity,waittimes,etc.,aswellaslocateanddispatchmobilecrisisdirectlytowheretheclientislocated.Itwouldbebeneficialtosharecrisissystemclientdatasothatclients’historiesinthecrisissystemareknownacrossallmodalities,andfollow-upisconsistent,anddatacomprehensiveandmeaningful.

RecommendationFour:DeterminehowtheCo-ResponderModel&MobileServicescanbeusedinacrisissituation.TheCo-ResponderModel,launchedin2018,partnerslawenforcementofficerswithbehavioralhealthspecialiststointerveneonmentalhealth-related911calls.Thesetwo-personteamsworktode-escalatesituationsbydivertingindividualsincrisisforimmediatebehavioralhealthassessmentsinsteadofarrest.BecausetheCo-Respondermodelissonew,itsimplicationsandimpactarenotyetclear.TheCo-ResponderModelinnotformallyacomponentofColoradoCrisisServices;however,itwouldbeworthwhiletounderstandtheimpactoneachsystem,howtominimizeredundancy,andhowtobetterleveragerelatedoroverlappingservicesasdataiscollectedthroughouttheModel’simplementation.RecommendationFive:Developandimplementanoutcomeevaluationsystem.Thecrisissystemwasdevelopedwiththeintentofprovidinggreateraccesstomentalhealthservices,ensuringColoradansgettherightservicesintherightlocationsattherighttime.Howthisismeasuredandtowhatcanbeattributedtoprogressisunclear.Anoutcomeevaluationsystemwillinvestigatetheextenttowhichthecrisissystemisachievingitsshort-termandmedium-termoutcomesoncethoseoutcomesaredefined.Itwillgeneratedatathatcandeterminetowhatdegreethoseoutcomesareattributabletothesystemitself.Itcouldmeasuretheeffectivenessofthesystem,andultimatelymakeitmoreeffectiveintermsofdeliveringtheintendedbenefits.Anoutcomeevaluationistypicallyimplementedafteraprogramhasoperatedforaperiodoftime,andshouldmeasureoutcomesagainstsettargets–whichmeansthattargetsneedtobeestablishedforthecrisissystem.Coursecorrectionscanbemadewhentargetsarenotreached.Becausethisareaissospecialized,theStatewillneedtocontractwithafirmtodevelopandimplementtheoutcomeevaluationsystem.RecommendationSix:EstablishaLeadershipCommittee.ThepurposeoftheLeadershipCommitteeistoprovideaconsistentqualityreviewoftheColoradoCrisisServices.TheLeadershipCommitteewouldincludeadiversesetofmembers,includingconsumers,communitymembers,hospitals,lawenforcement,andrepresentativesfrompublichealth,humanservicesandadvocacyorganizations.TheCommitteewillreviewprogresstowardoutcomes,aswellasidentifybarrierstoachievingoutcomes.TheLeadershipCommitteewillalsoidentifynewneeds(e.g.,publicsafety)anddeterminehowthecrisissystemcanaddressthoseneeds.HavingaLeadershipCommitteeinplacecouldpreventtheongoingneedforadditionalcommitteesandtaskforcestoreviewandmakerecommendationsrelevanttothecrisissystem.Additionally,theCommitteeshouldensurethatthevoicesofdiverseconsumersandfamiliesareintegratedintotheirmeetingsandconversations,andtheCommitteeshouldsolicitongoingfeedbackfromthesekeystakeholders.

RecommendationSeven:Improveintegrationofservicesformentalhealth/substanceabusedisorderwithinCrisisStabilizationUnits.Manypatientshaveco-occurringdiagnoses.Currently,theUniformServiceCodingStandardscodingmanualstatesthatnootherSUDservicescanbereimbursediftheyarebilledonthesamedayasdetox.OBHregulationscurrentlystate,“Innoeventshallafacilityadmitorkeepaclientwho…hasacutewithdrawalsymptoms,isatriskofwithdrawalsymptoms,orisincapacitatedduetoasubstanceabusedisorder.”Atpresent,perlicensingrules,MentalHealthandSubstanceUseDisorderclientsmustbekeptseparated.CreatingseparatesilosforMentalHealthandSubstanceUseDisordercasesiscounter-intuitive.Manyconsumersadmittedfordetoxalsohavementalhealthandmedicalneeds.Addressingtheseneedswouldhelpreducerecidivismandcontributetobetterpsychologicaladjustment.Inruralareas,thereisaneedtocombineMentalHealthandSubstanceUseDisordersduetolimitedspace(i.e.,smallerfacilitieswithfewbeds)andlimitedresources.TofullystaffadetoxfacilityandaCSUfacilitysidebyside,withonlyafewbedsineach,isinefficientandtoocostlyinruralareas.

RecommendationEight:Offerastatewide-integrateddataandresourcesystemfortheHotline.Anintegratedcrisissystemdatabasewouldallowforallcrisisproviderstodocumentandguidecrisissystemactivity.Regionalproviderswouldhaveincreasedconfidenceintheassessmentandtriagerecommendedbythecrisislineproviderbecauseoftheadditionalknowledgeofclientsbeingconsidered.Althougheachindividualprovidercurrentlyhasinternalandexternalfacingdashboardsoncoloradocrisisservices.org,dashboardactivitycouldbeexpandedtotheoperationssideofcrisisservices.Clientswouldbebetter

served,asserviceproviderswouldhaveaccesstounderstandtheirhistoryandhowtheirneedscanbestbemet.Itwouldbeeasiertofollowupwithclientsand/ortrackwheretheyreceivedservicesfollowingareferralor“warmhand-off.”RecommendationNine:Implementtargetedmarketingforthosepopulationsnotservedbythecrisissystem.Thereneedstobeananalysiscompletedtounderstandwhoiscurrentlynotbeingserved.Thiscouldbebetterunderstoodbyastreamlineddatacollectionandreportingsystem.Onlythencananappropriatemarketingstrategybedevelopedandimplementedtoensurethatthecrisissystemreachesallpopulations.

RecommendationTen:Exploreusinga3-digitnumberforcrisisline.Thecurrentstatewidehotlinenumberis844-493-TALK(8255).Inacrisis,itisalongnumberforapersontoremember.Itmaybebeneficialforthestatewidehotlinetouseaneworexisting3-digitnumber(suchas2-1-1,whichcurrentlyprovidesconnectionsforfood,housing,rent/utilityaid,emergencyshelter,etc.).Thefunctionsofthehotlineand211areverydifferentandcouldchangetheexperienceofthecallerdramatically.Thereisnationallegislationalreadyunderwaytoexplorethisoptionforthenationalsuicidepreventionlifeline,whichwouldimpactColoradoCrisisServiceslinevolumeaswell.Callerexperience,capacity,expertiseandcostsareimportanttoconsiderandneedtobestudiedcloselybeforeadecisionismade.

AlistofotherwidelysupportedrecommendationscanbefoundinAppendixA.

AdditionalRecommendations:DataTheColoradoHealthInstitute(CHI)wasengagedtocompletedataanalysisthroughoutthetimeframethattheSteeringCommitteemet.Threemajorthemesarounddataanalysisemergedaspartofthiswork:consistency,accuracyandthepresenceofdatagaps.Dataconsistencyreferstothepresenceofcontradictoryinformationdependingonthesource.Accuracypointstoconcernsoftheoverallcorrectnessofdata.Finally,thepresenceofdatagapsreferstotheinabilityofdatatoanswerkeyquestionsraisedbytheCommittee.

TABLE1:SummaryofDataAnalysisThemesTheme Description Examples

Consistency Differentvaluesindifferentsystems

Inconsistentdefinitions

SlightlydifferentvaluesofclientdemographicsinreportsfromCSOsversuscompileddatafromOBHbasedonmonthlyCSOdatasubmission

DifferencesbetweenCSOsonhowtheydefinedenominatorfornon-dispatchedmobileservices

Differentdefinitionsof“respite”

Accuracy GeneralconcernsAdministrativeerrors

PossibleincorrectlocationscodedforsomemobileservicesInvalidMedicaidIDsinHCPF-supplementedclaimsdatasetInvalidvaluesinclaimsdatacells(e.g.,firstnameslistedunderDOB)

PresenceofDataGaps

DatasilosDataincompleteness

UnabletoconnecthotlinedatatoCSOserviceprovision

Unabletoanswerquestionssuchaspayermixofclients

PotentialsolutionstotheseissueswereidentifiedduringCHI’sdataanalysis,stakeholderfeedbackandconversationswiththeSteeringCommittee,OBHandCBHC.Thesearediscussedbelowinorderofscope.

• Acentralizeddataandreportingsystemwilladdressmanyoftheproblemsidentified.Thissystemwouldcreatea

directconnectionbetweenasharedcrisissystemsdatabaseandelectronichealthrecords,ordesignateaspotforregulardatauploadsfromcrisisserviceproviders.Alldatapulls,includingdashboardsandkeyindicators,couldbebuiltoffasharedsystemandavailabletousersdesignatedthroughadataagreement.

Thissystemaddressestheproblemofconsistencybyeliminatingthepossibilityforcompetingvalues.Itaddressesaccuracybylimitingadministrativeerrorsduetotypos,whichoftenoccurwhenprocessesaremanual.Finally,shareddatabasesallowmoreflexibilityinansweringquestions—forexample,queriesmayberunoncustomagegroupings,orcross-tabulationscanbedonebygenderandcaresetting.

• Whetheronitsownorpartofacentralizedreportingsystem,thedevelopmentofadatadictionarywillgreatly

improvethedataqualityinthecrisisservicessystem,andthereforeallowformorerobustanalyses.Adatadictionarywillofferstandardandcompletedefinitionsforeverypieceofdatacollectedsothatthereisuniformityacrosslocationsandservices.Thiswillalleviatemanyoftheissuestouchingonconsistency.

• Currently,fewchecksexisttoensurethevalidityofdatacollectedwithincrisisservices.Athirdrecommendationis

toimplementdatavalidationsystemsandprocesses.Datavalidationcaninvolverelativelysimplechanges,suchastheuseofaformthatdoesnotallowuserstosubmitvaluesthatareinvalid(e.g.,charactersinanumericfield)ornonsensical(e.g.,anumberofclientsthatexceedsthenumberofvisits).

Theuseofdatavalidationiskeytoaddressingconcernsaboutdataaccuracybypreventingerrorsduetotyposormisunderstandingsofquestionsattheirsource.

• Afourthsolutiontodataissuesis,forthosewantingtolearnmoreaboutthecrisissystemanditsperformance,toidentifytherequireddatatheywillneedtogetacompletepicture.TheSteeringCommittee,serviceprovidersandotherstakeholdersshouldtakeaproactiveapproachinidentifyingwhattheywillneedtoproperlyunderstandthesystem.Whileashareddatabasewouldgoalongwaytoaddressingthisproblem,asthesystemexiststoday,dataofinterestmustbeidentifiedatthestartofserviceprovision—itcannotbededucedafterthefactifithasnotbeentrackedallalong.Thisaddressesissueswithdatagapsbyensuringthatquestionsaskedbystakeholderswillbeanswerableinthefuture.

• Astreamlineddatareportingprocesscansolvemanyoftheseproblemsaswell.Streamlinedreportingcanbeaccomplishedwithashareddatabase;yetevenintheabsenceofashareddatabase,amorestreamlinedprocessispossible.Theprocessshouldlimitmanualorduplicativeprocedures.Forexample,whencrisisprovidersreportdatatoOBH,OBHshoulduseamacrotohavethisdataautomaticallyinputintoatable,ratherthanusingamanualentryprocess.Thisaddressesaccuracyconcernsbylimitingadministrativeerrors.

• Theintegrationofdatacollectionsystemswillallowformorerobustreportingoncrisisservices.Onefrequentlycitedexamplewasarequesttointegratehotlineandmobileresponsedatacollectionsystems,butCHIsuggestsintegrationbetweenallservicesprovided,includingwalk-in,crisisstabilizationandrespite.

Thisintegrationwillservetoaddresstwoofthethemesidentified.Accuracywillimprovebecausedatafrommultiplesystemscannowserveascross-validation—forexample,whenvaluesonmobiledispatchesexceedvaluesofmobilerequests,thisflagsaninconsistencyinonesystem.Integratedsystemswillalsoallowformorerobustquestionsaskedbystakeholdersatmanyofthesemeetingstobeanswerableinthefuture.

• Finally,arelativelysimplewaytoaddresssomedataconcernsistoidentifythetimeframewithinwhichdataistrulyneeded.Withinthecrisisservicesreportinginfrastructure,apremiumiscurrentlyplacedondatafreshnessovercompletenessoraccuracy.DatasubmittedbyCSOsisoftenchangedafter-the-factduetoresolutionsinclaimsorotheredits.OBHmayconsiderwhetherJanuarydataistrulyneededinFebruary,orifthisinformationcanwaituntilMarch.Lesstimelydatamaybeanacceptablecostforthebenefits.

Improvementsinconsistencywillnaturallyfollowbyminimizingthenumberofdatasourceswithdifferingvalues—forexample,“January”valuesreportedinFebruarywillnowmatchthosereportedinMarch.Datawillalsobemoreaccuratebecauseoftheincreasedconfidenceincorrectvaluesatthetimethesearesubmitted.

ThereiscertainlyacknowledgementamongtheSteeringCommittee,CHIandotherstakeholdersthatnoneoftheserecommendationscomewithoutchallengesandconsiderations.Asharedstatewidedatabase,whileaddressingmanydataconcerns,isahigh-costandhigh-effortsolution,especiallyupfront.ItalsomayrequireprovidersattheCSOstoconducttheirworkacrosstwoplatforms—onethatfeedsintotheshareddatabaseandanotherusedfortheirnon-crisiswork.Inaddition,everyadditionaldatapointcollectedisanextraburdenonproviders,andthismustbeweighedagainstthedesireformorerobustinformation.

Finally,asneweffortsareundertaken,thecrisissystemmustremainvigilantthateverychangeprovidesatangiblebenefittotheclientswhoneedtheseservices.DataimprovementsmustalwaysbemadeinthecontextofadirectbenefittotheseColoradans.

AdditionalConsiderationsThroughoutthecourseoftheCommitteemeetings,therewereadditionalconsiderationsthatwereconsistentlyraised:

• Workforce.Coloradoisfortunatetohaveastrong,growingeconomy.Thenegativeresultofthatgrowthistheongoingchallengetofillmuch-neededpositionsincriticalfields–includingbehavioralhealth.Itisdifficulttorecruitqualifiedindividualswhoarewillingtoworkeveningsandweekendswithapopulationwhohascriticalhealthneeds–especiallywhenlicensedprofessionalscanearnahighersalaryinprivatepracticeandsettheirownofficehours.Itisequallydifficulttoretainthoseemployees.Positionsinthebehavioralhealthfieldareoftenstressful,whichleadstoincreasedturnover.Thisonlyimpedesthesystem’sabilitytoservepeoplewhoareinneedofservices.ItisevenmorechallengingintheruralandfrontierareasoftheState.Becausetherearesomanydifferentprofessionsthatarestrugglingtorecruitandretainqualifiedemployees,itwillbecriticalfortheBehavioralHealthsystemtodevelopcreativeinitiativestoattracttherightworkforce.Thereareanumberofwaysinwhichtheworkforcechallengecouldbeaddressed:

o Launchloanforgivenessprogramsthatincludenon-traditionaloutpatientserviceso OfferongoingworkforcedevelopmentforprofessionalstaffintheareaofCrisisServices(i.e.,a“crisis

track”atuniversities,colleges,etc.)o Createpartnershipsbetweenurbanandruralproviderstoleveragetheuseoftele-health

• Stigma.Almosteveryoneagreesthatstigmaisahugeissueandneedstobeaddressed.Therearealotofstepsthat

canbetakentoreducestigma–includingpubliceducation,thoughtfuluseoflanguage,integratingphysicalandmentalhealth–butitisamassivehurdletoovercome,andamindsetthatwillnotbeeasilychanged.Andyetitcannotbeignored.

• CulturalCompetency.Coloradohasagrowinganddiversepopulation.PerSAMHSA,culturalcompetence,theabilitytointeracteffectivelywithpeopleofdifferentcultures,helpstoensurethattheneedsofallcommunitymembersareaddressed.Culturalcompetencemeanstoberespectfulandresponsivetothehealthbeliefsandpractices—andculturalandlinguisticneeds—ofdiversepopulationgroups.IftheColoradoCrisisSystemistoserveallpersons,itmustreflectaculturallysensitiveenvironment.

• Transportation.GiventhelargelandmassofColorado,itisessentialtoimproveandscaleuptransportationto

improveaccesstocrisisservices.Thesystemcanhelpgetapersoninneedofservicestotherightplacewithoutinvolvinglawenforcementortheexpenseofanambulanceride.

• Awareness.Itiscriticaltoraiseawarenessoftheexistenceofthecrisissystemthroughastrongercampaign–orby

whatevermethodswillmakethemostsignificantimpressions–sothatmoreColoradansareawareofit.Itisimportanttoespeciallytargetat-riskpopulations,suchasadolescents,adultmen,andveterans.

• Cross-AgencyAlignment.TheColoradoDepartmentofHumanServicesshouldworkwiththeColoradoDepartment

ofHealthCarePolicyandFinancetoworktogetheronalltherecommendationsinthisreport,toaddressitemssuchasratesandfinances,aswellasmaximizefederalfunding.

AppendixA:CommitteeVotingTallyonAllRecommendationsRecommendationstoimprovethecrisissystemwerepresentedbytwosub-groupsatanall-dayworkshoponMay18th,atwhichtimeCommitteemembersinformallyvotedontherecommendationstheymostsupported.TheserecommendationswerecompiledanddistributedtothefullCommitteeforanelectronicvote.Thetablebelowreflectsthetop10recommendationsvotedinfavorbytheCommittee.

TABLE2:SummaryofRecommendationsReceivingtheTop10Votes

Top10Recommendations Yes,Isupport

No,Idonotsupport

Concerns

Increasethebreadthanddepthofservicesforyouthandchildren 13 0

Increasepeersupportinallareas 12 1 Sustainabilitycouldbeachallenge

Leveragetechnologytoconnectandsimplifythestateandlocalcrisislines 12 1 Resourcesaretoolimitedtoinvestintechnology

Co-respondermodel&mobile:Determinehowthatcanbeusedinacrisissituation

11 2 Sustainabilitycouldbeachallenge

Developandimplementanoutcomeevaluationsystem 13 0

EstablishaLeadershipCommitteetoreviewandupdateoutcomes,identifyadditionalgapsandneeds,etc.

12 1Unclearonwhowouldbeonaleadershipcommittee,howoftenitwouldmeetandwhatpoweritwouldhave;notoptimisticthatthiswouldbeaneffectivegroup

Improveintegrationofservicesformentalhealth/substanceusedisorderwithinCSU 12 1 Sustainabilitycouldbeachallenge

OfferstatewideintegrateddataandresourcesystemfortheHotline 12 1 Resourcesaretoolimitedtoinvestintechnology

Considertargetedmarketingforthosepopulationsnotservedbythecrisissystem

12 1Sustainabilitycouldbeachallenge;whilesupportiveoftargetedmarketingbutquestionthecostandhowtodothiseffectivelystatewide

Exploreusinga3-digitnumberforthecrisisline 8 4

Peoplemaythinktheyarecallingagov'tnumberandbelesslikelytousethehotline;211wouldresultinanadditionalstepforpeopleincrisis;211doesnothavecliniciansmakingdecisionsaboutwhetherdispatchisnecessary;arethereenoughcallstojustifymovingtoa3-digitnumber?;willonlysupportifservicesarenottransitionedawayfromRMCP;thecomplexitiesofusinga3-digitnumberaretoovastNote:1personrecusedhim/herself

Considertargetedmarketingforthosepopulationsnotservedbythecrisissystem

12 1Sustainabilitycouldbeachallenge;Whilesupportiveoftargetedmarketingbutquestionthecostandhowtodothiseffectivelystatewide.

TheCommitteedevelopedanumberofotherrecommendations,allofwhichweresupportedbythemajorityofCommitteemembersthatvoted.Tables3and4reflectthoserecommendations.

TABLE3:SummaryofOtherRecommendationsSupportedbytheCommittee

Recommendations Yes,Isupport

No,Idonot

support

Irecusemyself Concerns

EnsurethatthecommunityunderstandshowtoaccessCSUservices

12 1 0 Doesn'tmakesensesinceyoucannotself-admit

Increasemarketingtoraisepublicawarenessformobileservices 9 3 1

Beyondthescopeofthiscommittee;needtoensurethatmobileisequippedandreadytomanageincreasedrequestsforservicesstatewide;marketingdollarsshouldbedirectedatincreasingawarenessofthecrisisservices/systemingeneralandnotconfusingthingsbyfocusingononecomponent

Markettoschoolsand/orcreatepartnershipsformobileservices 12 1 0 Beyondthescopeofthiscommittee

Growtheuseofwalk-inclinicsthroughawareness&referrals 13 0 0

Broadenreferralbaseforrespitebeyondcrisisclinicians 10 3 0 Beyondscopeofthiscommittee;lesserprioritygiven

limitedresources

Improvecultural&linguisticresponsivenessthroughtraining,diversificationofstaff,morewelcomingandusefulinterpretationservices

11 1 1 SupportiveofculturalawarenessbutbelievethecurrentCSOsalreadydoagoodjob

Betterleveragetheuseoftechnologyformobileservices 10 3 0 Thisisalesserprioritygivenlimitedresources

Offermobiletrainingtodeliverservicestoyouth 10 2 1 Thisisalesserprioritygivenlimitedresources

Identifybetternomenclatureorbetterdefinerespite 12 1 0 Beyondthescopeofthiscommittee

TABLE4:SummaryofOtherRecommendationsSupportedbytheCommittee

Recommendation Yes,Isupport

No,Idonot

support

Irecusemyself Concerns

Improvedatacollection/analyze/answertherightquestionstounderstandtheimpactofthesystem(toincludeotherstakeholders)

13 0 0

Haveongoingdiscussionsrelatedtocrisiscasemanagement/in-homerespite

12 1 0

EstablishCSUlicense 8 2 3

WouldprefertoseestandarddefinitionofwhatyougetatanATUversuscommunityclinicwithbedcapacity;thereisalreadyabodyreviewinglicensingandweshouldaskthemtoaddressthis&providerecommendation(s)

Improvetransportationoptions 13 0 0

Createformalagreementtoclarifytherelationshipbetweenhospitalsandmobileservices

11 2 0 Thisisalesserprioritygivenlimitedresources;wewouldbehardpressedtodictateagreementstohospitals

Reviewprotocolsfordispatchversuscallcenter(formobileservices) 13 0 0

Considerexpandingthedefinitionorcriteriaforwalk-inclinics 7 6 0

Beyondthescopeofthiscommittee;needtounderstandtheexistingneedsincommunitiesfirst;toovague;walk-indefinitionisalreadybroadandappropriate

Includepayersinconversationandineducatingpeopleabouttheirbenefits(forwalk-inservices)

11 0 1

EvaluationandcapturingofdailycensusofbedsforCSUstodeterminebestwaystomaximizeutilization

11 2 0Beyondthescopeofthiscommittee;needtounderstandtheexistingneedsincommunitiesfirst;thisisalesserprioritygivenlimitedresources

Ensurebothmentalhealth/substanceusedisorderneedsaremetviarespite 9 3 0

Beyondthescopeofthiscommittee;wouldonlysupportifwenarrowtheservicetothoseincrisis,asitseemsbroaderthanthescopeofcrisisservices

Reviewlicensingrulestosupportintegratedsubstanceusedisorderandmentalhealthservices

10 0 2

Reviewlicensingrulestosupportintegratedsubstanceusedisorderandmentalhealthservices

10 0 2

AppendixB:SummaryofCommitteeMeetingAgendasandPresentations

Meetings CommitteeMeetingObjectives* Speakers/PresentationsMtg.13/9/18

● IntroduceroleandpurposeofCommittee● Reviewhistoricalnarrativeofthecrisissystem,andcurrentstats● Determinedecision-makingprocessanddefiningsuccess

SummerGathercole,SHGAdvisors;EmilyJohnson,ColoradoHealthInstitute

Mtg.23/23/18

Hotline● Reviewofstatewidehotlineandpossiblerecommendations

BevMarquez,RockyMountainCrisisPartners;EmilyJohnson,ColoradoHealthInstitute

Mtg.34/6/18

MobileServices● Overviewofmobileservicesandcurrentstatistics

LoriBanks,AuroraMentalHealthCenter;MaureenHuff,NortheastBehavioralHealth;EmilyJohnson,ColoradoHealthInstitute

Mtg.44/20/18

MobileServices● Clarificationonservices● BillingprocessesLessonsfromOtherStates● Arizona

MaureenHuff,NortheastBehavioralHealth;JasonDeaBeuno,AspenPointe;EmilyJohnson,ColoradoHealthInstitute;CamilleHarding,CDHSOfficeofBehavioralHealth

Mtg.55/4/18

Walk-inClinics,CrisisStabilizationUnits,Respite● Overviewofservicesandcurrentstatistics

MaureenHuff,NortheastBehavioralHealth;BarbaraKleve,AspenPointe;TeresaManocchio,ColoradoHealthInstitute

Mtg.65/18/18

AllDayWorkshop• StakeholderSurveyResults• OBH’sPerspective• ReportsfromWorkingGroups(Hotline&Mobile,andWalk-

in/CSU/Respite)• InformalVotingonPrioritizedRecommendations• StatutoryPrinciples

SummerGathercole,SHGAdvisors;RobertWerthwein,CDHSOfficeofBehavioralHealth;CamilleHarding,CDHSOfficeofBehavioralHealth;VariousCommitteeMembers

Mtg.76/1/18

● SchoolToolkitreleasedbyMentalHealthColorado● ConsumerStakeholderResults● Discussionofdraftoutlineofreportandrecommendations

AndrewRomanoffandSarahDavidon,MentalHealthColorado;SummerGathercole,SHGAdvisors

Mtg.86/15/18

● Reviewandapprovaloffinalreport

SummerGathercole,SHGAdvisors

*Thegroupagreementsandstatutoryprincipleswerereviewedatthebeginningofeachmeeting.