Speakers: Ms Erica Chestnut-Ramirez, Me Jamie Sellar and Stephen Scott
Stephen Scott: Good morning everyone, and welcome to this webinar for the Towards Zero Suicides initiatives and New South Wales Health. My name is Stephen Scott, I work at the New South Wales Ministry of Health. And this initiative will be focusing on the Assertive Suicide Prevention Outreach Teams Initiative, which is part of the Towards Zero Suicide suite of initiatives. These initiatives are supporting the delivery of the Premier's priority in New South Wales to reduce the suicide rate by 20% by 2023. Thank you all for joining us for this webinar. I'd like to start by acknowledging the traditional owners of the land on which we're conducting this webinar this morning, the Gadigal people of the Eora nation and pay my respects to the elders past, present and emerging. And I'd also like to acknowledge anyone with lived experience of suicide, who is tuning into or watching this webinar and acknowledge your contribution to suicide prevention and the criticality of your involvement. So, thank you also for being a part of this.
This morning follows a workshop that the Ministry convened on the previous Friday, which was focused on both initiating the co-design process for the Assertive Suicide Prevention Outreach Teams initiative and also looking at a range of models that are similar to this initiative from other locations in Australia and around the world. We are especially thankful for our two guests from the United States who are joining us for this webinar this morning, who also presented at that workshop on Friday. Erica Chestnut-Ramirez from EMPACT Suicide Prevention Centre in Arizona and Jamie Sellar from Crisis Now in Arizona. Now, the way that the webinar this morning will proceed is that I will throw over to Jamie very shortly, who will give you a brief overview of the Crisis Now model before a presentation from Erica, which will go for about half an hour on the particularly the outreach aspect of the Crisis Now model that is being implemented in Arizona. You are able to submit questions for our presenters and I will be able to relay those to our presenters following the presentation. You can submit those through the blue hand icon in the top right hand corner of your screen. So thank you again for submitting any questions, that you may have and we look forward to answering those. Just before I commence the rest of the webinar though. Just to give you a little bit of background on the, on the Assertive Suicide Prevention Outreach Teams initiative. This is an initiative that is funding a new team in every local health district in New South Wales. So 15 teams in total. With a estimated full time equivalent of four additional staff members. We anticipate that this will... This will consist of a mix of clinical and non-clinical or peer-based employees. And importantly, the purpose of these teams is to reach people in the community who are experiencing suicidal crisis, may not necessarily have a mental health diagnosis. Although of course if they also do they certainly a focus for these teams as well. And importantly to reach these people rather than those people needing to present to emergency, or other services such as the, such as the police or ambulance with their suicidal crisis. So we expect that these teams will start to make a really important new addition to our suicide prevention system in New South Wales. Now, I'll just introduce Jamie Sellar firstly from Crisis Now and ask Jamie to give us a bit of an overview of the Crisis Now model before we go to Erica's presentation. So thank you, Jamie.
Jamie Sellar: Thank you for having me. I'm gonna start a little by talking about what a crisis is. So here, we've been fortunate to go ahead and be part of the Assertive Suicide Prevention Outreach Team conversation that we had yesterday. In the US, only when we talk about suicide prevention, we're talking about crisis as a whole. So today we're really gonna talk about the Crisis Now model, which is not exclusively working with folks that have suicidal ideation, but anybody that's in a mental health or substance use crisis. So you gonna see as we talk, we gonna talk about Mobile Crisis unit, probably gonna use the word suicide very seldom because for us, what we understand is the mental health system needs to be able to support those that are currently in a episode of psychosis. Those folks that currently might have homicidal thoughts, might have some substance induced issues that are going on for them. But a subset of that, are those folks that are at risk for suicide, that is always considered a crisis and should always warn a behavioural health or mental health response going through. So I'm gonna talk a little bit about what's going on in the US and some of the changes that have been made over the last 30 years and how we respond to crisis services. So Crisis Now is a model that is currently endorsed by our National Association of State Mental Health Program Directors, which really are the behavioural health commissioners for all 50 States have gotten together and this is the model they endorse. And really at the core of the Crisis Now model is what we wanna do is ensure that there's a behavioural health response for anybody that's in a behavioural health crisis as opposed to how it frequently happens. Where the first responders in a crisis, are gonna to be either law enforcement or ambulance personnel, the facilities of choice for people who are in crisis tend to emergency departments, which are much better geared toward medical emergencies than behavioural health crisis. And frequently what we see in the United States is that jails sometimes do become a setting that people with mental health issues run into because there's no other options for them. So in 2014 to 2016, the National Association for Suicide Prevention for the National Action Alliance for Suicide Prevention commission the crisis service task force, to take a look at all 50 States and say, what's working, what's the best system that we currently have in place? And what they realised is that there was no system that was absolutely perfect, but there were elements. There were good elements that when combined together provided a safety net for folks that were in a behavioural health crisis. That was not only sustainable, but it was humane, it was effective, it was safe, and it was really the right thing to do for every community. So when we talk about the Crisis Now model, we historically talk about it as you know, the Arizona model, where both Erica and I come from or the Crisis Now model. And the reality is that Arizona right now is utilising probably, the highest fidelity of the Crisis Now model. And really, with the Crisis Now model talks about is an analogy to maybe the medical crisis system that we would see in the United States.
So if somebody has having chest pain, generally they would call 911. They would get an ambulance that would respond to their scene. And if the symptoms were severe enough, they would get transportation to a facility, primarily in emergency department. And if it could not be stabilised in the facility in the emergency department, they would be transferred onto a medical floor. And reality is, in the United States and most States, there's not a comparable system for folks that are in behavioural health crisis. So what the Crisis Now model talks about is we need a comparable system for those folks that are in crisis, that includes separate call centres that would act as kind of a 911 or a 999 dispatch, that's able to handle behavioural health calls. And then the overwhelming majority able to stabilise those calls on the phone. The second level, which would be kind of an analogy to an ambulance response would be, instead of having a medical response to those with behavioural health crisis, let's get Mobile Crisis Outreach Teams out there. That can help work in the field where people live, work and play to help them stabilise the situation that they're dealing with and help them to remain in community with the natural supports that they have there. And for those cases that cannot be stabilised in the community, we need a psychiatric emergency room or a place the facility that can provide safety and security, while people are (INAUDIBLE) are being able to be stabilised further around their crisis situations. And for those folks that can't be stabilised in a short period of time in facility, may be longer term, short term psychiatric inpatient program that can help them get to the point that they can return back to the community safely, in a situation that may take two or three days. So the reality is that there is no one component of a crisis system that by itself is gonna go ahead and solve a community problem. What we have seen is great impact when we employ a good mobile call..., good crisis call system that's able to work with people on the phone. Very good Mobile Crisis Outreach Teams, which we're gonna go in depth today. Facility-Based crisis services that can both provide short and longer term programming. To ensure that people get the right level of care at the right time. So frequently as we're travelling, we're talking about the model a lot of times communities want to go ahead and start with one particular element of the Crisis Now model. Really what we're gonna talk about today is Mobile Crisis Outreach Teams, but understand how they fit into the larger compendium of crisis services and the Mobile Crisis alone isn't going to solve the issues. Good call centre, great mobile teams, great facility-based services are really the hallmark of a good crisis system for you to go ahead and have. So with that, I'm gonna turn over to my colleague Erica. Erica and I have worked together, I'm gonna say probably about a decade now. At this point in Arizona, the program that Erica runs is seen as the exemplar in Crisis Now of how Mobile Crisis Outreach Teams should run. And we gonna do an in depth analysis on a little bit more about what it means to be a Mobile Crisis Outreach Team and with that, I turnover to Erica.
Erica Chestnut-Ramirez:Thank you Jamie. And I just wanna say thank you to Stephens and the ministry for bringing us here. This is obviously a long trip for us and it's been very fruitful, so I appreciate the opportunity. So thank you. So my name is Erica Chestnut-Ramirez, I am the regional vice president at LA Frontera EMPACT suicide prevention centre. Obviously you can see that in the name of my agency, it is suicide prevention centre, that is our main focus. And EMPACT actually stands for something. It's actually emergency mobile, paediatric and adolescent crisis teams. That is our beginnings, that is where we started. And we had very humble beginnings. I think the big takeaway for the listeners today is to know that the Crisis Now model has taken 30 years in Arizona to come to fruition. And this did not happen overnight. And so I think that's important to keep it in the forefront as well. EMPACT started with one Mobile Crisis team serving only adolescents and children who are at risk for suicide. And since then we've obviously expanded tremendously over the last 30 years and we've been able to have the system, that we have the opportunity to present to you today. So I'm going to start to talk about Mobile Crisis services and what that means. Jamie very eloquently talked about how Mobile Crisis, telephone services and crisis facilities fit into the Crisis Now model. This kind of our continuum for services. When you're looking at this inverted triangle here.
And we have our prevention services and our outpatient services, which serve kind of the most amount of people in the United States. And then you have your telephone centres, Mobile Crisis, your crisis facilities, and then your ED and your inpatient services. And the goal is that the smallest amount of people would be seen in the EDs, in the inpatient services. So this is kind of how Mobile Crisis fits into the Crisis Now model. So there's key precepts related to Mobile Crisis services. And the important thing here is to know that there's many ways to get there. It doesn't have to happen one specific way. There's different ways that you can meet these kinda goals and these overall precepts. So most importantly is that Mobile Crisis is community-based. It is not hospital-based. We don't wait until someone hits the ED or hits the inpatient, to go out and serve individuals. We are serving people in their community where they feel most comfortable. That could be in their homes. That could be on the streets, that could be behind the store in a dumpster. Yeah, we can serve them anywhere. That's the most important thing is that we are actually sending a team to actually go to wherever the individual is and meeting them where they are. It's not hospital-based. We have that service in the United States and we have that service in Arizona, but we call it hospital rapid response. We like to call things what they are in the United States. We're very kind of black and white in that way. And so we call that hospital rapid response where people go into the hospitals, do an assessment, try to do some discharge planning. That is not Mobile Crisis. Mobile Crisis is actually meeting the individual wherever they are in the community and helping them with whatever their crisis might be. The next thing is stabilisation versus assessment.
So we are not, Mobile Crisis is not an assessment and refer type of service. We do make referrals and we do connect people to ongoing services, but that's not our overall goal. Our main goal is stabilising the individual in their community, in their natural environment. We know, and research shows us that people do better in their natural environments, wherever they feel most comfortable, where they have people who they love surrounding them, whether that be their family, their friends, their pets. We know that people do better in those settings rather than contrived settings such as the hospital, jails. We, it's less trauma. That there's less trauma for those individuals when they're served in their natural environment. And these services are 24/7. So we want people to be served any time of day not just the typical nine to five type of outpatient hours that traditionally people see when they do counselling services. This is gonna be a 24/7 response and when we say quick, we mean quick. So we're talking in Maricopa County. We actually have a one hour response time for individuals, wherever they're located for any type of call that's coming from the individual or a third party. Now, if you have a police response, meaning that police is calling the crisis service asking for crisis mobile, that is reduced to 30 minutes. Our time frames and our funders' time frames are a lot different when it comes to law enforcement. They need a almost immediate response. And so that's under 30 minutes. So those are the time frames that we're shooting for. And I'll talk a little bit more about how we're able to get that. And then 2 person responses. So Mobile Crisis team is made up of two individuals. That's typically for us, a master's level clinician, somebody who has a Master's Degree in the behavioural health field. As well as someone who is considered a behavioural health technician and for us in Arizona, that is somebody who has a Bachelor's Degree in a related behavioural health field or someone who is a peer, someone who has lived experience who has at least four years of experience in the behavioural health field.
And so, those are our two person teams. That's what it is made up of and that serves us very well, often because it might not just be the specific identified client that we're working with. It could be a family, there could be many people in the home and so, having multiple eyes helps us with safety as well as helps us have different interventions going on at the same time so that's the reason for that model. And then, the big precepts that Jamie hit on as well is that emergency department and jail diversion are key to this program. We want to make sure that we are keeping people unnecessarily out of emergency departments and out of jail. That helps, say, with cost and it helps with person-centred care. It really reduces trauma for individuals who do not need to end up in emergency department and do not need to end up in jail because they are having a mental health crisis. And, all of our Mobile Crisis teams are deployed by a call centre so we have the air traffic control model that Jamie talked about related to a centrally dispatched service and all those calls are routed to the call centre and then they decide which Mobile Crisis team is able to go out on the individual or the family in crisis. And, another piece that's key for United States is that the majority of these mobile responses do not require a law enforcement response in addition and we'll show a little bit of the stats related to that a little bit later in my presentation. And, what does a mobile crisis team do? So, we are providing a crisis assessment including a comprehensive risk assessment. We are identifying whether a person is low, medium or high risk related to multiple factors whether that be suicide, homicide, substance use issues and psychiatric issues so, we're looking at the person as a whole, trying to figure out exactly what level of care that they need as well so, we're taking a look to see at what risk they are as well as what level of care would match that and what they need. And, obviously, we're doing the escalation and engaging individuals who are in crisis and trying to intervene and do appropriate crisis intervention training and skills with them. And then, we're safety planning with them and their family and friends as well, if they are involved, and that's a comprehensive safety plan. What does the person actually need to do? What do they need to follow through with? How do family and friends play a role in that as well to try and keep the individual safe in their community where we know that they'll have the best outcomes and then we're arranging for that higher level of care if it's necessary.
So, if somebody is high risk for detox or they are high risk for psychiatric symptomology and they need to go to a higher level of care or a crisis drop-off centre, we can arrange for that and we actually do transport when it's appropriate to do so. We do not overly rely on law enforcement to do our transportation of these individuals. We are doing a full assessment with them so we know what level of risk they are at and if they're safe enough for us to transport and then we have the individual sign a transportation agreement as well stating that they will follow through with certain things in order to keep our staff safe and the client safe as well as we are transporting them. And then we're also, as I mentioned earlier, we are following up and doing coordination of care so if we know that an individual is already set up with our outpatient services, we'll make sure that their clinic knows that they've had a crisis episode and we'll make that connection so that there's a follow-up appointment for that individual after the crisis or after they get released from inpatient services and we're making sure that individuals are not falling through the cracks. We want to make sure that people are getting the services that they need ongoing to keep them out of crisis. And then, our mobile crisis team will also, if somebody is unwilling or is unable to engage in treatment services and they are high risk, we have the ability to do emergent petitioning and non-emergent petitioning processes as well. And the goals, I think I've talked about it already and Jamie did as well in terms of community stabilisation, we know that individuals do better in their natural environments. It's actually, is very helpful for individuals. It empowers them for future crises. It helps build their confidence. If they know that they can get through whichever crisis they're experiencing today and they are able to enact some of those coping skills and things that they learn with the Mobile Crisis team, they have better outcomes later on so, they know that they're not being taught that they have to go to jail or they have to go to an emergency department to have other people manage the crisis for them. They start to feel empowered and it builds their confidence and, as I mentioned before, it's less traumatic so, being in a hospital environment when maybe they don't necessarily need to be there or being in a jail setting where they may not need to be there, can be extremely traumatising, especially when they're in the midst of a crisis and we know that when law enforcement shows up, they come with their lights and their sirens and it's very obvious that they're there, if they have Mobile Crisis services, it's not as noticeable that they are there. We show up in a minivan with two individuals and it truly looks like it's two old friends coming for a visit. It's an unmarked van and it is not meant to cause a lot of noticeability and it's obviously not lights and sirens. And then, obviously, we talked about reducing costs so we know that Mobile Crisis saves money, it truly does. It prevents the overuse, and the misuse, honestly, of emergency departments and jails and so, we want to make sure that we are being fiscally responsible as well by providing this service to individuals and to keep them out of those higher-cost services when it's not necessary for them to be there and, don't get me wrong, there are times when individuals do need to be there but we are able to help them be that gatekeeper for who is appropriate to be there and who is not. And then, I've obviously talked about reducing that trauma and that's extremely important related to Mobile Crisis services and it actually opens up opportunities for individuals to seek mental health services if it's less traumatic the first time that they do it. When they encounter Mobile Crisis, if they have a positive experience, they're more likely to seek services when they have a crisis next time in terms of Mobile Crisis. And then, we're obviously facilitating referrals for individuals, making sure that they get to the appropriate place and the appropriate treatment centres where they need substance use services or they need some general mental health services, we can obviously set up those referrals and make those appropriate recommendations for services. And then, as I mentioned, removing barriers to seeking mental health crisis care.
That is what I talked about before when somebody has a positive experience with a Mobile Crisis team, they're more likely, then, to say, oh, you know, mental health people aren't so bad, these helpy people. I'll look to them next time when I need some support in what I'm dealing with. And, collaboration with key partners in the community. This has been extremely important for us. As I mentioned, it's been 30 years of learning for all of us in Arizona with the Crisis Now model and there are some key partners that we have had to collaborate with. It wasn't that long ago that Jamie and I were, actually, from competing, if you will, agencies. We both provided mobile crisis services at the time and it wasn't always that we were great friends and that we could be together and we could speak about things. There were times when funders would pit us against one another and that has been a real learning curve for all of us to learn that there's plenty of crisis to go around and we've been able to really keep the mental health of individuals at the forefront, keeping the idea that we need to have healthy communities in the forefront and we've been able to collaborate and ensure that people get the best care possible. And, then there's obviously key partners and community stakeholders related to law enforcement, related to emergency medical services. We've had to build those relationships to ensure that individuals get the best possible care and that they don't have to utilise jail or emergency departments unnecessarily. And, how does this whole Mobile Crisis system work? How do we even get out there? So, essentially, as Jamie talked about before, we have this centralised dispatching service. All those Mobile Crisis calls that are dispatched actually, initially, come through central dispatch and they do that initial safety triage and coordination on the front end so, they are actually getting about 20,000 calls a month and they are only dispatching Mobile Crisis to about 10% of those calls. Some of those calls are able to be resolved and stabilised over the phone. Some of those individuals do need to go to a higher level of care and they can actually skip Mobile Crisis services and send them straight to emergency response and sometimes there are individuals that do need to have a law enforcement response as well and it isn't appropriate for Mobile Crisis to go out and so, that central dispatching function is able to take a look at that, see what is appropriate for Mobile Crisis and make that determination and then, about 10% of that 20,000 is being sent to Mobile Crisis to respond and that's important for Mobile Crisis because we know that we can respond without law enforcement to most situations. We can go to somebody who is in danger of suicide because it's not a safety situation for us in most times. They're looking to hurt themselves, not hurt other people, and so, we're there to help and to support them. One of my colleagues who is retired law enforcement has coined a term which he calls STO, which is actually Scary to Others, and that is a term because, sometimes, individuals who are manifesting symptoms of their own psychiatric issue can look scary to the average person. Somebody who is in the midst of a psychotic episode could look scary to another individual and that shouldn't stop mobile crisis from responding just because they're exhibiting signs and symptoms of their diagnosis. So, those calls come in through central dispatch, Mobile Crisis has been sent out, we have the two-person response and, I mentioned, who those people actually are, the Master's level clinician with the BHT or two BHT staff is an opportunity as well.
Our state actually requires a minimum of Behavioural Health Technician, and, again, that is somebody who has a Bachelor's level degree in a behavioural health-related field or somebody who has four years of experience within the behavioural health world so, typically for us, and for the other provider who provides Mobile Crisis services, we always have a Master's level clinician and then that person can be paired with a BHT or somebody who has lived experience as well. And then, what we're doing, our on-scene assessment, typically, when we get there, when Mobile Crisis gets there on scene, they are requesting a law enforcement response less than 5% of all responses so, in addition to the central dispatching really triaging to see if law enforcement is needed, when we initially get there, we're doing a quick scan to ensure that there's no weapons that can pose a threat to us. If there are, the individuals, the mobile team, can extricate themselves from the situation, call law enforcement first to try and kind of clear the scene, if you will, rid it of all weapons, so that then we can provide our intervention. And then, if police is already on scene because they've actually called us, the focus for Mobile Crisis is actually releasing them from the scene as soon as possible so that they can get back to their job of taking care of the community, keeping the community safe and keeping our own home safe. And then, the other thing that Mobile Crisis is doing, obviously, is the level of care determination and transport, so, we're identifying doing that full-risk assessment, seeing if they need, if they're high, medium or low risk and what level of care they need to address that and then transporting them from there. And then, this piece, I talked a little bit about it of why collaboration is so important so, in the United States, and this is obviously a little different here, law enforcement is often the first to encounter individuals who have mental health issues. We have done an amazing job in the United States where 911 is the true nexus to behavioural health, unfortunately. 911 is so highly publicised that anytime there's a situation, people immediately dial those three numbers and that means that law enforcement is going to be the first on scene so, law enforcement has done a great job with us in terms of learning from us about behavioural health issues and also, conversely, we've done an amazing job really trying to learn the needs of law enforcement and what they actually need from us.
We've learned that they are our customer as well and it's not just the client or the family that is our customer but, also, those people who we collaborate so, it's important when thinking about identifying and implementing Mobile Crisis services, who are your stakeholders? Who are your true customers in the community that can help you and can help you create this system that can be super effective? So, the other thing we learned was, you know, in behavioural health we don't want individuals who have mental health issues to end up in the criminal justice system. That makes our lives and their lives that much harder. We want to make sure that we can keep individuals in the community and can help keep them safe. And by collaborating with other partners it has really helped achieve our goals overall for the Crisis Now system. We wanna make sure that we can reduce suicides and that has been effective for us as well as having clients have improved outcomes. And being very efficient with our services. Really ensuring that there's not this stepping over each other and doing duplication of services we're able to really effectively move people through the continuum of care for services. And recovery opportunities for individuals is highly important when you're collaborating together with stakeholders. You have the ability to intercept with people early on in their situation, in their crisis. And you have the ability to really help them move through their crises much more quickly than they may have had they languished in the system. And then considerations, these are some of the things that we learned just by our collaboration with law enforcement. Making sure that we had quick and certain response times.
So there were times in our history not that long ago where police would call for a Mobile Crisis response and it would take hours and hours and hours for us to get them. We learned, and had to learn very quickly, that law enforcement will move on very quickly. They are very big problem solvers. They have a problem in front of them and they will figure out a way to get it done. And so that usually means sending someone to jail when they probably don't need to be there. And so it was important for us to know that we need to be quick about this, we need to get to them quickly. Hence the 30 minute response time. And that consistency really ensured them that they knew we were coming. It wasn't gonna be this, "We're waiting for three hours, and we're just sitting around waiting for them." And they knew that once we got there if we released them quickly from the scene it was, "We got this. We can do this. We have this. You can go back to your job of being a police officer. You don't need to be a counsellor, that's our job. We are in the business of mental health, we are not in the business of policing. You're in the business of policing, you don't need to be mental health workers." And so that was extremely important. And that helped build trust between law enforcement and the behavioural health system. And they no longer felt like we were dumping on them and that they had to take care of our clientele. We also realised that just the mere presence of law enforcement escalated crisis for individuals. Individuals may have a history of trauma with being around law enforcement. And so just the visibility of the uniform or the car made the crisis go from five to 10 in a very brief period of time. So we learned that we do not need to have that type of response if it's unnecessary to do so. So having that type of relationship between behavioural health and police has been extremely helpful for us. So in terms of law enforcement they are requesting Mobile Crisis teams over 3,000 times a year. And of those 18,000 mobile responses less than 1,800 required any police response. So very low numbers in terms of all those calls that are coming in through the crisis line being sent to Mobile Crisis.
And then if we have police on scene it's less than 5%. And then the majority of individuals that we're seeing are stabilised in their community. It's truly only about 10 to 15% that need to go to a psychiatric facility. And then we have a very small percentage of individuals who are unable or unwilling to seek voluntary services so we do have to follow through with the involuntary process. And then we do have some individuals obviously who are needing detox as well. So about 75 to 80% overall are completely stabilised in their community. And that is huge in terms of cost savings as well as person-centric care. So this is kind of those numbers. 20,000 crisis calls coming in through the dispatch centre. Less than 10% of those are resulting in Mobile Crisis dispatch and less than...well less than 1% from the crisis call centre are resulting in a police response on the front end. Once Mobile Crisis goes out - anywhere from 1,600 to 2,000 times a month, less than 10% of those are requiring law enforcement response. And 75 to 80% of those individuals are being stabilised in their community. And of those needing a higher level of care less than 3% are actually transported to an emergency department where there might be a medical issue. So we have very small usage of ambulance services which can be very costly as well. And then our crisis observation admissions, as I said, 75 to 80% stabilised and discharged to the community on the Mobile Crisis side. But it's about the same numbers for crisis OVS units. So those crisis facilities who are seeing individuals they have a window of time to be able to see those individuals, assess them for a brief period of time, and then get them stabilised and discharged back out to the community. And they have very similar rates in terms of their stabilisation rates as well. And then the involuntary admissions there's actually very few that end up being true involuntary because often somewhere throughout the process they're able to convert that individual to be voluntary.
So it really goes to show that the use of engagement with individuals really does help reduce those involuntary admissions. And to be truthful in many of these areas, all areas actually, call centre, Mobile Crisis, and in the crisis OVS units we have the use of peers. And so they are extremely helpful in this process in terms of engagement. They are so much more effective many times than masters level clinicians. Me as a masters level clinician there's only so far I can go in terms of engagement, and I may not have that type of lived experience. And so the use of a peer who may have some of the same feelings, some of the same experiences, can really connect so much deeper. So it's been extremely helpful. So I've tracked a little bit about some of these lessons learned. But in terms of staffing some of the things that we really had to shift for our staff when we were developing this, and again, remember, we started 30 years ago with one Mobile Crisis team and one call line. And now we have over 30 Mobile Crisis teams that are in our community that work 24-7. To give a little bit of perspective Maricopa County has 4.5 million individuals living there, and we span about 9,500 square miles. So it's a very large piece in terms of geography that we have to cover. And so it's definitely taken us a while to get to this point. So in terms of our staffing the typical outpatient model that we have is that we sit in an office and we wait for individuals to come to us for therapy. And that is not Mobile Crisis and that is not Crisis Now. And so we really had to make a shift. And there is truly a type of personality if you will for individuals who want to go out into the community and who want to do this type of work. And the trick is finding those individuals and how do you recruit for them, and how do we get them, and how do we keep them engaged in this type of service as well? We have individuals that work at our agency from the day that we opened. There is one individual who just had his 33rd anniversary of working for us in Mobile Crisis. He's a lifer, he is the one that stayed from day one. And that is his personality.
He likes that. He likes the individual - that it's not the same thing every day. It keeps him on his toes and that's the type of work that he loves. And so we really try to find out what are those key characteristics of individuals who like that type of work. And then, you know, that type of shift work. Our staff work four 10s. And so a lot of times they go over shift and so you have to figure out how do you compensate individuals for that because it's not typically 40 hours. So there has to be some overtime, has to be some type of differential, so to speak, for them in terms of pay. That's one thing that we have learned. And other things would be cultural as well. So we do have a large Spanish speaking population in Maricopa County. And so we have had to really recruit individuals who speak different languages so that we could be able to meet the needs of the community. Obviously here in Australia you're very rich in culture and that's going to be important as well to have a representative workforce for you to be able to connect with other specific populations. In terms of under expectations something that we had to wrap our brains around is that they kinda held the key. So we had to make shifts based on what they wanted from us. We initially thought 70% would be a good number to hit for community stabilisation and they said, No, that's not good enough. You need to hit 75." And that was their expectation. So we had to make some shifts. And what that meant for us is that we had to be creative and think outside the box of how we were going to be able to hit that, making sure that people were safe in the community. That may have meant that we needed to stay on-scene with an individual a little bit longer.
To work with them a little bit longer to make sure that they could feel safe in their community. And then changing the perceptions of our staff as well. I talked a lot about law enforcement and the idea not to keep law enforcement on the scene unnecessarily. That idea that, you know, Oh, we can't go alone. It's night and night time is scary and we don't do things at night." That obviously had to shift. And we provide a lot of training to our staff and provide a lot of support. So they have 24-7 access to supervisors where they are able to staff situations. Anytime they feel unsafe they know that they can back out and they can call a supervisor to staff the case to make sure that they stay safe and that nothing adverse happens. And then in terms of our core measures I talked about our response times. Time to release - that's time to release law enforcement. We wanna make sure that it's quick. So we do track those kinds of things - how many times do we get on scene when police is there and how long does it take you to release them? It shouldn't take much longer than five minutes to do a quick assessment and say, OK, you can go. We've got this. We're gonna deal with this crisis. And then community stabilisation obviously, we wanna make sure that we hit the 75 to 80%. In terms of response times for Maricopa County we are required to have an hour, like I said, and 30 minutes for law enforcement. Throughout the state of Arizona the expectation from the state, because we do have some areas, not Maricopa County, but other areas of the state that they have up to two hours because they are very rural. We even have frontier land in Arizona where you will go for miles without seeing another individual. So that has been important as well in terms of keeping those core measures in our forefront. And then the role of peers - understanding how important peers are, and how important that is for our clients and our families that we're serving. And I talked a little bit about those rural considerations as well as the cultural and language barriers that existed for us and what we needed to learn. The training of our staff, like I talked in terms of, culture 101 was kind of the training that we gave to our staff related to learning about law enforcement and what their ideas were. Learning about obviously the key pieces of theories and principles of crisis management. Have a big focus on family systems theory in crisis and how you manage working with an entire family and not just an individual. And then obviously having good crisis de-escalation skills, good risk assessment and crisis intervention skills. And then how do you work with special populations. Again, working with veterans who have a very high risk of suicide in the United States, as well as the Native American population, and the elderly as well. So understanding those populations and how suicide has effected those populations even more so than the general public.
And I think that's about it. It's time for some questions I think.
Stephen Scott: Thank you very much for that Erica. That was incredibly detailed and really contained a lot of very useful pointers for us I think in going forward. We have a few questions that are coming in, so in the time that we have remaining, which is about 15 minutes. If you'd like to continue to submit your questions using the blue hand icon on the right hand corner of your screens, you're most welcome to do that. Just to start with though, I think one of the most critical questions for us is, of course, how to get started. And, I guess with this question, I would just ask you both to maybe cast your minds back to the very beginning and to see if you could identify for us what might be some of the top recommendations that you would have for a state like New South Wales that is particularly focusing on establishing these mobile teams at the moment.
Erica Chestnut-Ramirez: You wanna start?
Jamie Sellar: Yeah. I can go ahead and start. So, you know, the reality is in Maricopa County right now, we've got 30 teams every day that are up and running. I would not anticipate that New South Wales would be able to start with 30 teams. It's kind of an end point to get to. So with most things, you look at a stage in a phased approach and you say, we're going to start small, we're going to learn our lessons, we're going to expand, we're going to learn additional lessons, we're going to expand some more. So in reality, when I would start to look at in the stage in phased approach is not to overreach. So if I were starting this, if I was tasked with this, I would look at a geographical area that maybe had high utilisation, high need, maybe four square miles, maybe eight square miles and I would start with one team that was centrally dispatched through the call centre and I would start to expand as we started getting things under our feet. So the reality is the four million people that you have in Sydney for example, probably are going to require 30 mobile teams, 28, 25 mobile teams at some point to get the kind of outcomes that we see in Arizona. But they're only as you wouldn't start with that. So what I would look at is where your high need areas are first. I would go ahead and start. I would get my culture down to where we were seeing everybody cause a lot of times mobile teams will start and they'll say we're not going to see anybody who's intoxicated. Well you have to, a lot of folks are going to be intoxicated. We're not going to see anybody that doesn't want to see us. Well you have to. If Erica calls and I'm in crisis, I may not want you to come out, but a crisis team is the most appropriate response at that point. And you get your culture and that can do attitude in place and then you start to extrapolate it to other areas. So I would look at a stage in phased approach, there's going to be a wide learning curve and if you don't get it right initially, what you're going to do is follow a system that is suboptimal and you're just going to have a large suboptimal system. And quite frankly, in most States and probably in New South Wales, you've got a large system that is suboptimal. We wouldn't be out here discussing other systems if it was working the way it was supposed to. So I would start small, I would anticipate, you know, years to get to the point where you've got every nook and cranny of your communities, with coverage. But you want to make sure that as you're moving into new places, it's going to be the right product at the right time and done in the right way.
Stephen Scott: Thank you. Did you have anything to add, Erica?
Erica Chestnut-Ramirez: Sure and I think that, you know, when we first started, I mentioned we had one Mobile Crisis team serving children and adolescents. The other mobile team provider was serving adults. And so what we looked at was we actually looked at the hours of day of operation as well. So initially we may have looked at children and most of the calls that were coming in were related to school hours. And so we were able to, you know, put a team during those school hours to kind of get the, the biggest bang for your buck. For the adults it was a little different and it was more off work hours where the most crisis kind of occurred, that after 5:00 PM and so they were able to kind of stage them that way and look at hours of, of optimisation as well.
Jamie Sellar: It's a really well, and what I can talk a little bit about is where I've seen it, difficulties in implementation in, in other communities. You know, first and foremost, I can't over emphasise the role of a good call centre that is doing the triage for this. Many communities decide that, what we're going to do is have the mobile teams do their own triage. So if me and Erica are a team, for example, they anticipate, a lot of folks will anticipate that me and Erica can carry a phone and if somebody is in crisis, they can go ahead and call us and we'll talk to them on the phone and if need be, then we'll go out. The reality is a good call centre is going to triage about 90% of the calls away from using a mobile outreach team. If you've got a two person team, I should be doing interventions in the field, I shouldn't be doing my own screenings. So first and foremost, you have to get the dispatch system down and the triage and the call centre down so that your mobile teams can be most effective. And what I have seen is that when you try to skimp on the call centre aspect, the mobile team response times get hurt, the outcomes get hurt and then at some point you're saying mobile teams aren't working. And it's not that they're not working, they're just not working the way that they're supposed to be working.
Stephen Scott: Right and the context of the system that they're working in, it's not...
Jamie Sellar: Right. Stephen Scott: Promoting the greatest effectiveness at all times. And that's a really important point for us and we are looking at ways that we can integrate these teams into our current, phone-based crisis systems as well because we, we do have a few of those already and we of course want to build on those and I'll just move to quite a few questions that we have coming in now. So thank you for all of these. And if we don't get to all of them in the time available, we will have them answered and posted on the New South Wales health website. I'm just to let you know in advance as well that Erica's presentation will be uploaded on the New South Wales health website along with the webinar as, as well. So you will have that available to you. Firstly, an interesting question which he touched on a little bit, Erica, that it's I think a little more focused, has this model been applied in some quite small populations of 40,000, 10,000 and even less than 2000, so very remote areas. And if so, what was the, what was the resource related implications of that? Was it applied with the same resources as described?
Erica Chestnut-Ramirez: So I can speak for, for impact specifically because we have some that have the, this, the crisis dispatched through the call centre. We also have our own little mini call centre, if you will, [laughter] for our own private contracts. And we have a lot of tribal contracts where we have contracts with multiple native American tribes and we are, actually have a little bit of a different model in that the other model is more firehouse model. What we call you have people who are on shift ready and waiting to go. In some of the smaller populations has been more of an on-call basis where the call centre will then call someone who might be at home, might be asleep in the middle of the night, and then can be dispatched quickly and meet up with their partner and go to, to that scene. That is when we talk about there's multiple ways to get there. There's other ways that you can do that too. So that's what we have found that has been effective with working with small tribal entities.
Stephen Scott: OK. Thank you very much for that. There's an interesting question here, do the, the clinicians and peer workers always agree on the need for someone to be involuntary and what happens if these two workers are not in agreement about that?
Erica Chestnut-Ramirez: That's a good question. No, they do not. [laughter] They do not always agree. And usually what will happen in that case is that, I was talking about the supervisor that is on call, they will call the on call and they will staff with the, the clinical supervisor and then the supervisor will make that call and it will be their decision.
Stephen Scott: OK, so there's an escalation?
Erica Chestnut-Ramirez: There is a process. And if the supervisor does, they don't agree there, then it goes up to the next level, which is usually me.[laughter]Stephen Scott: OK, good thank you for that.
Erica Chestnut-Ramirez: You're welcome.
Stephen Scott: Now, this is an interesting question about age as well. Given that you started with a service for children and adolescents. But you've over time grown to be covering the lifespan. So how do you keep staff comfortable and skilled with all of these age groups?
Erica Chestnut-Ramirez: It really is about training and keeping up with the, the best training so far. And there are some individuals who may have not been able to make that shift, didn't want to make that shift. And so there could have been a natural attrition at that point of they didn't want to serve adults, so they found somewhere else that they needed to go.
Stephen Scott: OK. And just as a similar question, which I did want to make sure that we got to is what strategies do you have for supporting people who are peer workers in your service particularly in terms of supervision and, and ongoing professional development?
Erica Chestnut-Ramirez: Yeah, it's a good, it's a very good question. And, I know that both of our agencies have peer support academies essentially, so the peers that are doing this work get extensive training on the front end in terms of what is appropriate to share about their experience, what is not when, or all those things, one of those boundaries so to speak. And then also in terms of, they get the same training that the, the other master's level clinicians do. We have a crisis basics training essentially, that's a couple of weeks training for anybody who works Mobile Crisis. And they are able to basically get training on anything that they may see. And identifying risk and, and what are the offsetting factors and other protective factors for individuals for, for suicide. And then in terms of ongoing supervision, they get consistent ongoing supervision with the supervisor for the Mobile Crisis team. They are able to, whenever they have a difficult situation that they may have done or completed a call, they can, they're going to staff with the supervisor, the supervisor can provide support and kind of, debrief that call with them so to speak, and be able to provide the support that is needed for them and ensure that they're able to either go on to the next call if they're not, if they're not doing well, we're able to call those teams down and say, we need to take them down because we need to provide additional support for them. Please don't send them out on another call. So it's, it's very fluid in that way and we try to be as supportive as possible.
Jamie Sellar: I think there's some advantages. That's one of the advantages to a two person team as well. Now you've got two people out in the field saying something and they can process that, there's a lot of work that's going on in the van between calls after calls, at dinner, going ahead and processing what they just saw in a very immediate way. One of the things that we have seen is when we're working with our peer staff is that traditionally in the US you never talked to staff about where they are emotionally. You know, there's some human resource regulations and if you find out that, you know, somebody has some mental health issues, if you treat them in a day, it becomes kind of one of those, litigation kind of risks. But the reality we've made a conscious decision that we're going to ask our peers how you're doing, and we're going to create a safe place for them to go ahead and respond to us about how they're doing as well. Part of that is the, the human connection. So for us, our international currently is about 50% of our workforce, of our 1100 staff are going to be pure, are going to be folks with lived experience. So we become very adept at being able to support them in weekly supervision, not just the technical aspects of the job, not just the, you know, routine of how you're working, but really how are you responding? How is this impacting? How are you growing? The other thing that was kind of mentioned in there that I do think is important to note is workforce development. So typically I'm a master's level clinician. I've got a lot of opportunity to advance my career, like move into supervisory role, like I'm, I'm a, I'm a clinician, I move into an executive role. But the concept is peers frequently don't have those same career paths. So we've done a lot of work of trying to establish leadership positions for folks that have peer status, whether that's a certified peer support specialist one, they can move into two with experience and a little bit more education three and then into team lead types of positions as well so that someone can take, someone, can be a peer and identify a career path for them that they can make a lifelong commitment to do certified peer support work. Very important to have a career path so you don't get folks burned out three years saying I'm doing the exact same thing I was doing three years ago.
Stephen Scott: Right. Yeah, it's an excellent point and really, something that perhaps doesn't get thought about in relation to peer workers actually. Now, it's a really a key area I think to consider for the future. Now, we are in our final seconds of our time for this webinar, so we may just leave the questions there. A number have been covered in our, in our Q and A session here. But there are a couple of we have not been able to quite get to. So, we will make sure that those are answered additionally by our American guests and posted online with the webinar and with Erica's presentation as well. I'll, I will just refer though to one question that's arisen, which is more for the ministry regarding the implementation of the initiative in particular how much of this model is prescribed and how much will be co-designed at the regional level. So we are funding a co-design process at the district level for this initiative. The workshop that was held on the previous Friday to this webinar was geared towards developing some state-wide guidelines, that will help direct the shape of that co-design process at the district level, but which at the same time is overly prescriptive and allows a certain degree of district level flexibility and responsiveness to the local service system and the local community. So with the time that we have allocated essentially out now, I will just thank Erica and Jamie again for coming all the way to Australia and helping us out with both the workshop on Friday and this webinar today, Jamie and Erica will also be holding a few extra meetings with some of our local health districts over the next afternoon and a day or so as well. So we thank you very much for the support and time that you have so generously given to us, in these days and we wish you a safe journey back to the United States. Thank you to everyone who has tuned in online for this webinar and also to anyone who is watching it subsequently. As I said, the webinar and the presentation, as well as the questions that we were not quite able to get to will be posted online on the New South Wales health website. There is a page especially for the Towards Zero Suicides initiatives with a lot of extra information and various other resources that are being put together through all of this work located there. We will of course have future webinars, again very soon, related to other Towards Zero Suicides initiatives. And we look forward to seeing you again then. So thank you very much for tuning in and have a great day.
