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Distant dream nearing reality

One-stop-shop for crisis intervention moves forward

IOWA CITY– What once seemed like only a good idea, and a bit of a dream, is nearing realization in Johnson County as plans for a comprehensive, “one-stop-shop” for addiction and behavioral short-term care recently took a giant step forward.
People undergoing a substance abuse or behavioral crisis pose a unique challenge for law enforcement personnel, as traditionally, options have been limited to a hospital emergency department (ED) or jail. Neither facility is, in many cases, the most appropriate choice. Memphis, Tennessee, and San Antonio, Texas, both pioneered a new approach to dealing with such cases: getting people specific help and diverting them from jail and the overloaded criminal justice system.
Both programs put the emphasis on early recognition by responding law enforcement officers (LEOs) who are able to take subjects to a specialized facility. The San Antonio program includes a comprehensive campus known as The Restoration Center, which is available 24 hours a day for LEOs to bring in persons who are intoxicated or experiencing a mental issue. Key to the San Antonio model is Crisis Intervention Training (CIT) for the officers. All San Antonio officers undergo a 40-hour training program focusing on behavioral issues and how to handle them while determining the most appropriate facility for a person.
While CIT typically refers to the initial training LEOs receive, Jessica Peckover, Johnson County’s Jail Alternatives Coordinator, said it is a five-legged stool encompassing comprehensive identification and treatment for behavioral issues including substance abuse.
Those five legs, she said, include: the initial training for officers; forming community partnerships among public, private and non-profit agencies and organizations; engaging advocates; developing a comprehensive and accessible, readily-available crisis service delivery system; and training for behavioral health and how to engage with the justice-involved population.
“The two legs we’ve been the most focused on in the last two years has been developing the 40-hour training and looking at that accessible crisis service delivery system,” Peckover said.
Johnson County is following the San Antonio model and has been sending officers from the sheriff’s office and several police departments within the county since 2015. Various city and county officials have also gone to San Antonio to sit in and observe the training. Johnson County held its first in-house program in March 2017 with the ultimate goal of training every officer in the county, as well as expanding the training to include dispatchers, the first point of contact for a person experiencing a crisis situation.
“The goal is to have three (classes) per year,” she added, noting the goal has been met. “That’s the part we’ve come the farthest with, so far, because that’s up and running.”
When San Antonio’s training program was utilized, only a handful of officers could go at any one time, were gone for a week, and their agency had to not only pay their salaries, but also for lodging (the training was free, but all other expenses were borne by the law enforcement agency sending the officers).
The training includes an overview of several diagnostic categories including: mental health, substance abuse, intellectual disabilities, developmental disabilities and autism. Verbal de-escalation is also featured, as one goal of CIT implementation is to reduce on-scene tensions and reduce, if not eliminate, the need for an officer to restrain a subject in crisis. De-escalation reduces the risk of injury or death to officers and persons in-crisis, and also enables the officers to hopefully build a rapport with the subject while determining what services and facility are best. Extensive scenario-based education (role play) is built into the program to give the officers a daily chance to put into practice what they’ve learned.
The 40-hour training really requires a village, Peckover said.
“It takes a lot of partners to put that on,” she said.
In addition to law enforcement agencies committing their CIT instructors to the week, local care providers such as Dr. Christopher Okiishi, a psychiatrist in North Liberty with Meadowlark Psychiatric Services, donate their time throughout the week as well.
A “resource fair” during the week gives officers the opportunity to meet the people behind the area’s social services and see what options and resources are available to them when dealing with a person in crisis.
Forty volunteers also participate in role-playing exercises throughout the week, she added.
“So, it really takes a community to make this happen,” Peckover said. “I’m always surprised it comes together, every time, and every time, we have enough role-play actors, everyone shows up and does their thing.”
While getting the in-county training program up and running, focus was also given toward a Restoration Center-type facility.
“We’ve been calling it ‘The Access Center,’” Peckover said.
Once the officers realize jail or the emergency room are not suitable destinations for a particular person, a suitable destination must be found. Facilities like San Antonio’s Restoration Center, and the future Johnson County Access Center address this.
“We know that jails and EDs are not great settings for people with behavioral health crises,” Peckover said. “It’s not a great setting for anyone experiencing a crisis; it’s not a great experience for anyone there with a 6-year-old. We understand it’s not a great way to do it.”
The trend, she said, has been to develop these one-stop-shops where an officer can bring a person in, and be back out on the street in 15 minutes rather than waiting in an emergency room for several hours.
Peckover and others in the CIT movement envision a facility with a sobering unit, a detox unit, crisis observation/crisis stabilization unit and a permanent home for the winter shelter, which has had to find a new location for the past three years.
The sobering unit, she said, would provide a four-to-six hour length of stay for an intoxicated person who can’t safely stay where they are, but also do not require medical treatment. “It’s identified as a ‘harm reduction approach,’ and a public intoxication (charge) diversion option,” she said. A heavy emphasis would be placed on staff and peers engaging the people brought in, and determining who needs substance abuse treatment and transfer to the detox unit.
The detox unit, Peckover said, would be similar to that found at Prelude Behavioral Services, a not-for-profit organization providing substance abuse and behavioral health services in Iowa City, Marengo, Washington, Tipton and Des Moines; and would provide additional detox beds in the area. Having medical staff on-site would be key to making the detox unit viable, she noted.
Crisis observation, Peckover said, is a 23-hour stay for somebody in psychiatric distress. “It gives us a place for you to stay and let us monitor you for a period of time to figure out what is it that you need,” she said. “Do you need to go inpatient? Do you need to go to crisis stabilization for a longer period of time? Do you need a medication adjustment? Are there just some psychosocial things that are happening that we can problem solve for a little bit, and then get you back out into the community?”
The crisis stabilization unit would provide beds for those needing a little longer stay (up to five days), but not necessarily needing to go inpatient (hospital admission). “You’re not actively suicidal, like you need inpatient psych care,” she said. “But you just aren’t in a place where you can go back home, so this gives us a period of time where we can keep you here, keep you safe, get you stabilized on medications, try to find a good treatment plan for you to leave here in a better place than you came here.”
Peckover said the observation and stabilization units would be a major piece of the Access Center.
“Part of the mission is, we want to provide quick access to triage and crisis stabilization,” she said. Another key component is the linkage to community resources, with the goal of connecting people with the appropriate services.
People in crisis often call 9-1-1, which triggers a tiered response involving LEOs, the fire department and Emergency Medical Services (EMS).
Peckover gave the hypothetical example of a lonely, probably depressed, maybe even elderly person who calls 9-1-1 knowing that if they mention “chest pain” or “hard time breathing,” that within minutes, friendly firefighters will be there.
EMS responses are the bulk of the alarms firefighters respond to, and in North Liberty for example, account for multiple “runs” per day, putting an ever-growing strain on volunteer firefighters.
“It is absolutely the case that we want all first responders to have access to this (training),” Peckover said.
Dispatchers will be incorporated into the 40-hour training starting in March, she noted.
In addition to training more officers, and gathering data on their in-field efforts, plans for the Access Center are moving ever closer to fulfillment as a coalition of government agencies, municipalities and many non-profit organizations have banded together around this common cause.
The Johnson County Board of Supervisors recently announced the county will put funds toward a facility, and would also help cover any operational shortfalls financially. The board also sent out a white paper to all of the municipalities in the county detailing the percentage they would like to see contributed toward the project.
But Peckover said other local governments want to see an operational budget before committing funds.
Whether a new building is constructed from the ground up, or an existing building is purchased and renovated, an estimate of $6.5 million is on the table.
“So, we have an idea, but we don’t have the specifics until a property is purchased,” she said. The county is actively looking for a specific property, she added. In the meantime, meetings continue to work out the operational details.
The University of Iowa Hospitals and Clinics’ emergency department has been identified as the entity to essentially run the operation, she said, with sub-contracting to various non-profit organizations to provide specific, specialized staffing.
The goal is to put already trained and experienced providers in the Access Center rather than having to hire and train new personnel to staff it, she said.
Discussions continue on the operational details, she said. “There’s a lot of work to be done in that area to bring it to actualization.”
Peckover optimistically guessed the Access Center could be up and running within two years, depending on how quickly the county can acquire a property.
Whether new construction or remodeling, the physical work could take 18-24 months, she said.
In the meantime, contracts and 28E agreements would have to be drawn up and approved between the many entities, policies and procedures drafted, and many other details large and small worked out.
“I can’t imagine it any sooner than two years,” Peckover said, “It’ll happen as soon as it can.”
She sees the county’s commitment to providing funding in the fiscal 2019 budget as a big step forward.
“Things are happening, it’s really really slow, and then things happen really fast, and slow again,” she said. “There’s a lot of bureaucracy. There’s also a lot of really committed people, but that’s just the nature of it.”
The steering committee meets every two weeks with representatives from the municipalities, the university, the non-profits and the county.
“They’re all really committed to the cause, and the questions have been about, ‘how do we make this happen?’” she said. “It’s not been a question of if this is something we should do, but how can we possibly do it?”