ContentsIntroduction . 4About TBD Solutions . 4Purpose of Handbook . 4Scope and Function of CRPs . 12Philosophy of Care . 13Staffing . 21Infrastructure . 25Referrals, Admissions, and Intake . 27Discharge. 34Outreach/Follow-Up . 35Funding . 37Regulations and Governance . 39Metrics and Outcomes . 44Community Relations . 47Safety Net. 50Challenges . 53Conclusion and Opportunities . 549/6/2018 TBD Solutions LLC - 20181

TBD Solutions would like to thank all of the providers, behavioral health administrators, and advocatesthat contributed to the Crisis Residential Best Practices Handbook through survey responses,participation in interviews, and conference discussion.Specifically, we would like to mention the following programs for their substantial participation in ouryear-long workgroup (completion of 80% or more of the workgroup surveys):9/6/2018Aurora Mental Health CenterAurora, COBaltimore Crisis Response, Inc.Baltimore, MDBay Cove Human Services, Inc.Boston, MABirch Tree CenterDuluth, MNBurkeLufkin, TXCharleston Dorchester Mental Health CenterCharleston, SCCOMCARE of Sedgwick CountyWichita, KSCommunity Access, Inc.New York, NYCommunity Reach CenterWestminster, COCommunity Research Foundation, Inc.San Diego, CACornerstone MontgomeryRockville, MDCREOKS Behavioral Health SystemSapulpa, OKDenton County MHMR CenterDenton, TXDuPage County Health DepartmentWheaton, ILFamily & Children’s ServicesTulsa, OKHope NetworkGrand Rapids, MIHuman Development Services of Westchester, Inc.Mamaroneck, NYIntegral CareAustin, TXLegacy Treatment ServicesMount Holly, NJMADO HealthcareChicago, ILMHMR of Tarrant CountyFort Worth, TXMosaic Community ServicesTowson, MDNetcare AccessColumbus, OHPathways, Inc.Ashland, KYPresbyterian Medical ServicesSanta Fe, NM TBD Solutions LLC - 20182

Productive Alternatives, Inc.Fergus Falls, MNRegion 6 - Life Help Mental Health ServicesGrenada, MSRegion IV Mental Health ServicesCorinth, MSResources for Human DevelopmentPhiladelphia, PARI InternationalPeoria, AZRiver Edge Behavioral Health CenterMacon, GARosecrance Health NetworkRockford, ILSo Others Might EatWashington, DCTexana Crisis CenterRosenberg, TXThe Harris Center for Mental Health and IDDHouston, TXWaubonsie Mental Health Center, Inc.Clarinda, IAWestern Montana Mental Health CenterMissoula, MTYour contributions and participation in this process are greatly appreciated.9/6/2018 TBD Solutions LLC - 20183

IntroductionApproximately 20% of the population struggles with a mental illness at any time1, and suicide is the 2ndleading cause of death for people under age 352, yet the United States does not have a behavioral healthcare system that adequately meets the needs of its most vulnerable citizens. While treatment hasadvanced and stigma has waned, we are still faced with a health care system with pronounceddisparities in access and quality between physical health care and mental health care, and manycommunities lack a comprehensive continuum of services to assist and support people in psychiatriccrisis.When a country possesses the resources to reduce suffering among its people but does not exercisethem, it cannot be considered great. As Mahatma Ghandi said, “The true measure of any society can befound in how it treats its most vulnerable members."Crisis Residential services are a cairn3 on the trail of a person’s mental health treatment, providingagency, dignity, and hope to individuals experiencing a mental health crisis. In an industry where fear,exploitation, and segregation have permeated treatment, Crisis Residential services invite a newparadigm of connection and recovery into the pursuit of stability and wellness.This guide to Crisis Residential Services was developed to inform and offer perspectives on a highlyeffective model of services that is under-utilized and not well-documented in the national literature inhopes that more communities will consider enhancing their response to mental health crisis through theuse of this alternative to psychiatric hospitalization.About TBD SolutionsTBD Solutions is a consulting, training, and research company based in Grand Rapids, Michigan. Since2011, TBD Solutions has helped behavioral health providers, payers, and administrators answer some ofthe most challenging questions facing the industry and the people served by them.For more information, visit of HandbookDeveloped through crowdsourcing and dialog with national crisis programs, this handbook is intended toprovide insight and perspective on how providers and communities are innovatively delivering criticalbehavioral health care to those experiencing a crisis. While decades of empirical research have beenconducted on psychiatric hospital alternatives, a qualitative analysis of this magnitude has not beenexecuted by any public or private entity with broad distribution.1Substance Abuse and Mental Health Services Administration (2017). Key substance use and mental healthindicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No.SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, SubstanceAbuse and Mental Health Services Administration. Retrieved from for Disease Control. Leading Causes of Death Reports, 1981-2016. Retrieved e.html3A cairn is a mound of rough stones used as a landmark to guide hikers and travelers along their journey (seecover photo).9/6/2018 TBD Solutions LLC - 20184

This handbook is geared towards two audiences: those who are currently operating Crisis ResidentialPrograms who seek to standardize and improve their practices, and those who are considering openingsome type of alternative to psychiatric hospitalization or other intensive service to support peopleexperiencing a mental health crisis.Approach & MethodsIn 2016, TBD Solutions developed and led a comprehensive national workgroup to develop a BestPractices Handbook for Crisis Residential services. Over the course of one year, this multi-agencycollaborative, consisting of over 150 Crisis providers, administrators, and payers from 45 statescompleted monthly online surveys and convened telephonically to share their experiences about thecritical components of their Crisis Residential Programs.As there are approximately 600 CrisisResidential Programs (CRPs) in the UnitedStates, this workgroup created and collected anunprecedented amount of information aboutthese programs. This was accomplishedthrough a crowd-sourcing model that includedproviders of all sizes and dimensions with minimalbarriers to participation. Nearly all data includedin this report comes from the structuredresponses and anecdotes of workgroupparticipants unless otherwise noted.LimitationsWhile the survey and data collection process forthis guide provides more comprehensive datacollection around Crisis Residential Programs thanhas ever been collected, it still only representsapproximately 10% of all CRPs nationally.Referencing Persons ServedIndividuals receiving inpatient mental healthtreatment have been referred to by manydifferent names, including patient, client,consumer, resident, guest, individual, andperson served. This report is built upon thefoundation of recovery-oriented principles inmental health treatment and choosing the leaststigmatizing language. We have chosen to usethe word “client” when referring to a personreceiving services as it is universally understoodwhile being less stigmatizing than words like“patient” and “consumer,” and it was the mostcommonly used term by survey respondents.While many of the principles identified in this handbook are universal to CRPs serving individuals of allages, over 95% of participants represented adult CRPs, likely revealing a bias in the data towards adultCRPs4.While participation was offered to Crisis Residential providers and advertised on national listservs andonline forums, participation required some level of balance and availability on behalf of the provider,and providers who are struggling, have more challenging programs, or have less resources at theirfingertips may be under-represented in this handbook. What’s more, crisis providers who can barelykeep their head afloat may find it difficult to reference resources such as this one to help manage theiroverwhelming challenges and move from a state of mere survival to one of thriving and sustaining.4Of the approximately 675 Crisis Residential Programs identified as of August 2018, about 80 (12%) provideservices to youth.9/6/2018 TBD Solutions LLC - 20185

Overview of Crisis Residential ServicesCrisis Residential Programs serve individuals experiencing a mental health emergency in a communitybased setting. As one component of subacute crisis stabilization services, CRPs provide a criticalcomponent of a healthy behavioral health crisis services continuum, offering substantial benefits whencompared to psychiatric inpatient hospitalization—namely, comparable outcomes5, comparable clientsatisfaction, and substantially lower costs6. Over 40 years of research supports the efficacy and value ofthe Crisis Residential Model. Crisis Residential Programs distinguish themselves from these other levelsof care due to their home-like environment, blended psychosocial model of care, multi-day lengths ofstay, and healthy mix of autonomy and accountability.Mission/Purpose of Crisis Residential ProgramsCrisis Residential Programs assist individuals experiencing a self-defined behavioral health crisis thatprevents them from maintaining a healthy life in the community, such as depression, anxiety, psychosis,and suicidal ideations. Services are delivered in a person-centered environment, meaning muchattention is given to the environment and treatment approach such that clients feel welcomed,affirmed, and validated. Clients play an active part in the treatment planning process, providing input ontheir goals for treatment.In some ways, CRPs resemble a halfway house model used in substance abuse treatment, in that theyare recovery-focused, community-based, and often found in a neighborhood or residential setting. Theycan be used as a stepdown from more acute treatment services, and they utilize a familiar communalenvironment to provide treatment and encourage prosocial skills. CRPs across the U.S. are successfullyused as a diversion or alternative to inpatient psychiatric treatment.The Crisis Residential Model varies between communities based on need, capacity, and funding.Crisis Residential Model Key ComponentsUnlocked FacilityLength of Stay Longerthan 24 HoursTreatmentProgramsHowever, the three main concepts used to distinguish crisis residential from other models of care are itsunlocked environment, length of stay greater than 24 hours, and treatment provided.TaxonomyWhile this study was an effort to build consensus around crisis services, the programs struggled to findcommon language to name the services they provide. Including the term “crisis” in the title of these5Bola, J. R., & Mosher, L. R. (2003). Treatment of acute psychosis without neuroleptics: two-year outcomes fromthe Soteria project. The Journal of nervous and mental disease, 191(4), 219-229.6Adams, C. L., & El-Mallakh, R. S. (2009). Patient outcome after treatment in a community-based crisis stabilizationunit. The journal of behavioral health services & research, 36(3), 396-399.9/6/2018 TBD Solutions LLC - 20186

programs seemed like a misnomer to some, as most clients seemed to be past the most acute phase oftheir crisis by the time they were admitted (for example, a suicide attempt). “Residential” gave theillusion of a long-term stay well beyond the typical 3-10 day stay that most clients experience in thesetypes of programs. Despite these disagreements, the phrase “Crisis Residential” will be used to refer tothese programs throughout the handbook.CRPs take on a variety of names depending on the terminology employed by the state behavioral healthauthority7: Crisis Residential Unit: California, Hawaii, Michigan, New York8, Pennsylvania, Texas9,Washington10Crisis Stabilization Unit: Alabama, Colorado, Indiana, Kentucky, Minnesota, Mississippi,Missouri, Ohio, Oklahoma, Rhode Island, South Carolina, Tennessee, Virginia, West VirginiaFacility-Based Crisis: North CarolinaCrisis Respite: Arizona, WashingtonCommunity Crisis Stabilization: MassachusettsCrisis Resolution Center (Class III): OregonWellness Recovery Center: UtahHistory of Crisis Residential ServicesFormal Crisis Residential Programs took shape in the United States following President John F. Kennedy’ssigning of the Community Mental Health Act in 1963, but their origins trace as far back as communitycaretakers who provided refuge to their citizens. Amidst the psychiatric counterculture of the 1960’s,programs like Soteria and Diabasis house began opening homes that were voluntary and unlocked. Thisnew concept of treatment seemed paradoxical, but researchers found that people would want to stay ifthey felt they had control of their treatment11.Many of the first CRPs were focused on serving those experiencing psychosis or diagnosed withschizophrenia. These facilities offered medication-free or limited medication treatment, a divergingpractice from the psychiatric hospitals at the time12. Arguably the most famous Crisis Residential7States listed in this section meet the aforementioned criteria of unlocked facilities providing mental healthtreatment with lengths of stay greater than 23 hours, and program nomenclature was verified through providermanual language or program descriptions.8New York also has Crisis Respite Centers, which align more with Peer Respite programs.9States like Colorado, Tennessee, Texas, and Washington maintain multiple versions of locked and unlocked Crisisprograms. Colorado has Crisis Stabilization Units (secured programs with delayed egress) and Crisis Respite Units.Texas has Extended Observation Units (locked facilities for 48-72 hours), Crisis Residential Units (3-7 day LOS), andCrisis Respite Units (7-14 day LOS). Tennessee’s Crisis Stabilization Units have a length of stay of up to 4 days, withCrisis Respite services utilized for stays longer than 3 days. Washington has unlocked Crisis Respite Centers andCrisis Triage Facilities, and locked Crisis Stabilization Units.10In Washington, Crisis Residential Centers serve youth in crisis, while Crisis Respite Centers and Crisis TriageFacilities serve adults.11DeWyze, J. (2003, January 9). Still Crazy After All These Years. San Diego Weekly Reader. Retrieved n, T., Ferriter, M., Huband, N., & Spandler, H. (2007). A systematic review of the Soteria paradigm for thetreatment of people diagnosed with schizophrenia. Schizophrenia Bulletin, 34(1), 181-192.9/6/2018 TBD Solutions LLC - 20187

program, Soteria, was developed out of a study formulated by the National Institute for Mental Healthin 1973. Psychiatrist Loren Mosher conceived the Soteria program, which was staffed largely withlaypersons and used medications sparingly. Mosher’s inspiration for Soteria came from his time spent atKingsley Hall, a similar experimental psychosocial treatment facility in England13. When he returnedfrom his time at Kingsley Hall, Mosher, working for the National Institute of Mental Health at the time,drafted a grant proposal for a 5-year study for Soteria (meaning “salvation” in Greek), and later for asecond home called Emanon (“No Name” spelled backwards)14.After Mosher’s time with the National Institute for Mental Health ended, he was instrumental in thedevelopment of two of the oldest CRPs in the United States: Crossing Place in Washington, D.C. andFenton-McAuliffe House in Rockville, MD. While both of these CRPs were further removed from theSoteria Model, they built the foundation for psychiatric hospital alternatives in the eastern UnitedStates.CRPs emerged across the United States in the 1970’s for a number of reasons. As state psychiatrichospitals closed in concert with national deinstitutionalization efforts, an estimated 560,000 peoplepreviously hospitalized became in need of care elsewhere15. Community-based services, including grouphomes and CRPs, filled some of the treatment gaps for those who were previously institutionalized butstill in need of care. Some communities opened crisis programs as pilot projects to decreasehospitalizations, while others have found Medicaid waiver funding or grants to expand the crisis servicearray. Other communities opened crisis programs to save money or to improve treatment for symptomseverity as a viable alternative to inpatient hospitalization. Some states have expanded their crisisservices in response to a tragic event16.CRPs have evolved and expanded throughout the United States since their inception in the mid-1960’s,taking shape based on the funding, treatment philosophy, and direction (or lack thereof) of the statebehavioral health entities.The stories of the 450 CRPs are maintained anecdotally by the tenured historians of the behavioralhealth systems. However, the stories of CRPs that have not survived—whether because of fundinginsolvency, utilization challenges, or poor management—are at risk of being lost. Without properattention, their lessons do not heed adequate warnings to current and future CRPs.13Lichtenberg, P. (2011). The residential care alternative for the acutely psychotic patient. Psychiatric quarterly,82(4), 329-341.14Hawthorne, W. B., Green, E. E., Lohr, J. B., Hough, R., & Smith, P. G. (1999). Comparison of outcomes of acutecare in short-term residential treatment and psychiatric hospital settings. Psychiatric Services, 50(3), 401-406.15Torrey, E. F. (1997). Out of the shadows: Confronting America's mental illness crisis. New York: John Wiley.Excerpt retrieved July 26, 2018, s/asylums/special/excerpt.html16Colorado Department of Human Services, Office of Behavioral Health (November 2017). Expansion of theColorado Crisis System Report (C.R.S. 27-60-103 (6) (b)). Report. Retrieved from: 7n3ujVHBrwcXFQNUVTNXdwN2s/view?usp sharing.9/6/2018 TBD Solutions LLC - 20188

Crisis Residential and the Crisis Services ContinuumCrisis Response and CrisisTreatment services haveexpanded greatly as providersand communities have engagednew and promising efforts toprovide meaningful treatmentinterventions. Inpatientpsychiatric hospitals have theirorigins in the asylums built inthe United States in the early1800’s17, psychotherapybecame popular in the early-Steve Fields1900’s, but it was not until theExecutive Director, Progress Foundation1970’s that the CrisisResidential model began to takeshape in the United States.Since then, the followingtreatment options have grown in size and popularity:"If you don't have, in your county,a fully staffed Crisis Residentialtreatment are hospitalizing peoplewho don't need to be hospitalized." Crisis Call Centers/Walk-In Centers: Crisis Call Centers and Walk-In Centers provide frontlinesupport to individuals in crisis. Crisis Call Center employees provide critical support through deescalation, active listening, and referrals to community resources. In some communities, CrisisCall Centers can dispatch mobile crisis teams, or schedule next-day follow-up appointmentsdirectly with outpatient providers. Walk-In Centers are often co-located with other types ofCrisis services, offering assessment and referral services.Mobile Crisis Team: Mobile crisis teams provide emergency screening, assessment, and triage atthe point of the crisis, with the goal of referring people to the appropriate level of care, andsubsequently serving as a diversion from an Emergency Room or Psychiatric Hospital. Mobilecrisis teams typically include a clinician (usually licensed) and a medical professional (RN), PeerSupport Specialist, and/or police officer. Many communities have also implemented CrisisIntervention Training18 (CIT) for law enforcement officers to gain specific skills in responding to amental health emergency.Psychiatric Emergency Services (PES)/ 23-hour Crisis Stabilization Unit (CSU): PES facilitiesprovide emergency psychiatric care to individuals that would often otherwise frequent the localEmergency Department to seek behavioral health treatment. Individuals typically have access toan interdisciplinary team consisting of nurses, social workers, prescribers, and sometimes PeerSupport Specialists.17Whitaker, R. (2001). Mad in America: Bad science, bad medicine, and the enduring mistreatment of the mentallyill. Basic Books, p. 15.18For more information on CIT, visit 6/2018 TBD Solutions LLC - 20189

Peer Respite: Peer Respite programs are completely operated and staffed by people with livedexperience with a mental illness19. No medical staff are present in the home, and individuals stayfor a period of a few days to a few weeks.Inpatient Psychiatric Hospitals: Inpatient psychiatric hospitals provide the most intensive andexpensive level of services, designed for people who are in severe emotional distress withsymptoms of depression, anxiety, psychosis, and/or are at risk of harm to self or others.o Partial Psychiatric Hospitals provide day treatment options with medical oversight forpeople who are ready to discharge from an inpatient setting but still need clinicalsupport and medication monitoring.Crisis Services ContinuumCrisis CallCenter/Walk-InCenterPeer RespitePsychiatric EmergencyServices/23-hour CrisisStabilization talBenefits of Crisis Residential vs. Psychiatric HospitalizationOver 40 years of research provides compelling evidence that Crisis Residential Programs providecomparable treatment to psychiatric hospitals, meeting the triple aim goals of better outcomes20, higherclient satisfaction21, and lower cost22. Care in CRPs is often provided in less restrictive settings with amore home-like environment, allowing more freedom and client choice while promoting moreengagement between clients and staff.Diversity in Treatment OptionsCRPs offer payers and clients a meaningful alternative to inpatient psychiatric hospitalization throughtreatment in an accessible, comfortable, and person-centered treatment environment. The program istypically unlocked, and treatment is typically voluntary, in sharp contrast to psychiatric hospitalization.19For a toolkit for evaluating peer respite programs, visit kit/.Polak, P. R., & Kirby, M. W. (1976). A model to replace psychiatric hospitals. Journal of Nervous and MentalDisease.21Hawthorne, W. B., Green, E. E., Lohr, J. B., Hough, R., & Smith, P. G. (1999). Comparison of outcomes of acutecare in short-term residential treatment and psychiatric hospital settings. Psychiatric Services, 50(3), 401-406.22Fenton, W. S., Hoch, J. S., Herrell, J. M., Mosher, L., & Dixon, L. (2002). Cost and cost-effectiveness of hospital vsresidential crisis care for patients who have serious mental illness. Archives of general psychiatry, 59(4), 357-364.209/6/2018 TBD Solutions LLC - 201810

Better OutcomesStudies comparing CRPs and inpatient hospital settings show similar or better clinical outcomes inpeople using the crisis residential settings over hospitals23,24,25. Favorable clinical outcomes includedlevel of functioning, symptom severity, self-rated symptoms scales, and self-esteem.Higher Client SatisfactionCRPs are designed as home-like settingsthat contrast the sterile, clinicalatmosphere of an inpatient hospitalsetting. In controlled studies, clientsreceiving services from a CrisisResidential program often report higherlevels of satisfaction withtreatment26,27,28,29. A comfortable andinviting treatment environment with lessfocus on medication and restraintprovides individuals the freedom anddignity they deserved.“The clients could dash out nude intothe street if they had to; we didn't likeit, but they did! You see, we wantedthem to be in this house of their ownfree will. They had to realize theirown desire to belong in the house,and they did.”- John Weir Perry, Founder of DiabasisLower CostAs the workgroup survey results revealed, Crisis Residential Programs can vary greatly in cost from oneregion of the country to the next, but typical CRPs cost approximately 300 to 450 per day, about 5060% of the cost of a psychiatric hospital per day.23Greenfield, T. K., Stoneking, B. C., Humphreys, K., Sundby, E., & Bond, J. (2008). A randomized trial of a mentalhealth consumer-managed alternative to civil commitment for acute psychiatric crisis. American Journal ofCommunity Psychology, 42(1-2), 135-144.24Howard, L., Flach, C., Leese, M., Byford, S., Killaspy, H., Cole, L., . & McNicholas, S. (2010). Effectiveness andcost-effectiveness of admissions to women's crisis houses compared with traditional psychiatric wards: pilotpatient-preference randomised controlled trial. The British Journal of Psychiatry, 197(S53), s32-s40.25Thomas, K. A., & Rickwood, D. (2013). Clinical and cost-effectiveness of acute and subacute residential mentalhealth services: a systematic review. Psychiatric Services, 64(11), 1140-1149.26Hawthorne, W. B., Green, E. E., Folsom, D., & Lohr, J. B. (2009). A randomized study comparing the treatmentenvironment in alternative and hospital-based acute psychiatric care. Psychiatric Services, 60(9), 1239-1244.27Greenfield, Ibid.28Osborn, D. P., Lloyd-Evans, B., Johnson, S., Gilburt, H., Byford, S., Leese, M., & Slade, M. (2010). Residentialalternatives to acute in-patient care in England: satisfaction, ward atmosphere and service user experiences. TheBritish Journal of Psychiatry, 197(S53), s41-s45.29Thomas, Ibid.9/6/2018 TBD Solutions LLC - 201811

Percentage of surveyed crisis homes30%What is your per diem rate for your crisis home?n 4125% 24%20%20%15%12%10%10%7%7%5%5%2%5%5%2%0%0%0%Per diem Rate*arrangement is outside of a per diem structureScope and Function of CRPsCrisis Residential Programs represented in this study ranged in tenure from less than 6 months to over30 years. They function in a variety of ways depending on their community, but over 90% of surveyparticipants stated that their crisis program existed to help divert people from the psychiatric hospital.Choose the features that best describe your crisis home.93%73%73% of facilitiessurveyedoperate as aStep-Down39% of facilitiessurveyedindicated a mainfeature of theirprogram is JailDiversionfrom PsychiatricHospitals93% of CRPs operate as aDiversion to PsychiatricHospitals9/6/201812.5% of CRPs indicatedthey operate as atemporary housingunit TBD Solutions LLC - 201839%n 5612

Treatment is varied and dynamic within each Crisis ResidentialProgram, based on funder preference, cultural expectationsaround client choice or treatment philosophy, or practicallimitations.THE HISTORY OFMINDFULNESS IN CRISISRESIDENTIAL PROGRAMSPhilosophy of CareCrisis Residential Programs were formed to providecommunity-based care to individuals in a psychiatric crisis,serving people in a more humane and compassionate way thanwas previously offered in a psychiatric hospital. While somecomponents of treatment are reflective of the Medical Model30(psychiatry, nursing, and pharmacology, for example), mostprograms provide a blended model of care that promotes theRecovery Model31 as well as components of the MedicalM

Texana Crisis Center Rosenberg, TX The Harris Center for Mental Health and IDD Houston, TX Waubonsie Mental Health Center, Inc. Clarinda, IA Western Montana Mental Health Center Missoula, MT Your contributions a