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This month, the Substance Abuse and Mental Health Services Administration, in partnership with the Federal Communications Commission and Department of Veteran’s Affairs, has established 988 as an easy-to-remember expansion of The Lifeline (formerly known as “The National Suicide Prevention Lifeline”). Americans will have one place to turn to for mental health crisis. Similar to how we are familiar with calling 911 for emergency police or medical situations, 988 will be a source for behavioral and mental health crisis situations. Establishing the 988 program is a bold first step for a community’s crisis care system, providing trained personnel to talk to a person in need. However, there is a general opinion that the framework necessary to establish a full system of mental health crisis care has not yet been established. This would include not only “someone to talk to” (988) but also “someone to respond” and somewhere to go.”

Image: Alliance Health Lafayette Medical Center

The Lifeline will put care at the fingertips of those in need and a greater volume of people will seek support. Without a new system in place, the 988 rollout has the potential to overwhelm current response teams and places. For the built environment specifically, it will put a strain on already-crowded Emergency Departments, and In-Patient Behavioral Health Units. The conversation at the intersection of mental health care and design is evolving as the care system grows.

Behavioral Health
Behavioral Health
Crisis Care Center Emergency Room

The Emergency Department has long been recognized as an ill-suited space for those in a mental health crisis. The Emergency Department is not set up to calmly receive those in crisis, provide dignity, privacy, or to truly treat those patients in a manner specific to psychiatric health. Thus, individuals are often transferred to an inpatient Behavioral Health Unit within the hospital. These units are often over-crowded, and the process can take time. With proper care, studies show most mental health emergencies are resolved within 24 hours. There is a need for a short-term place for individuals to stabilize from crisis and receive the tools needed for longer-term mental health. We expect to see innovative programs and building uses emerge to alleviate the pressure.

Crisis Care Center Emergency Room

Behavioral Health Crisis Units adjunct to an Emergency Department and Behavioral Health Crisis Care Centers out in the community can fulfill the “somewhere to go” component of care. Out of every 100 people that contact 988, it’s expected that 6 will need a place to go. More acute patients and situations will benefit from Crisis Units adjunct to an ED or on a hospital’s campus. Crisis Care Centers out in the community are appropriate for non-acute situations. Both acute and non-acute Crisis Care offers a safe place for a person in mental crisis to go for a few hours up to a few days. With a similar mission to stabilize and support community heath, the design approach is similar for both crisis centers. However, the acute setting dictates a different programmatic approach. For both acute and non-acute Crisis Care Centers, the vetted and credible Behavioral Health Design Guide and the Facility Guidelines Institute (FGI) hold exceptional recommendations for the owner, care team, and design team to incorporate. The Facility Guidelines Institute included new recommendations in the 2022 edition for this emerging care to guide the design of safe and effective care environments for Hospital and Outpatient settings.

Behavioral Health
Behavioral Health
Behavioral Health Care Center

Community Crisis Care Centers | Community based Crisis Care Centers fulfill the need for someone in a mental crisis as a place to go for non-acute care. Here, the focus is stabilization and connection to community resources for long term success. Unique programmatic considerations in the flow of an individual’s mental care include a “warm handoff” where a peer greets the person upon arrival. Resources for comfort and stability are available, including shower facilities, laundry, and nourishment. The individual’s treatment needs are assessed – whether that’s medication adjustment, connection to counseling services, or other community outreach programs. Most individuals become stable within 24 hours, but a few require observation for extended periods, typically 2-5 days. The facility can accommodate these several days stays. The community-based Crisis Care Center accommodates similar functions as in-patient and ED adjunct Crisis Care – balancing the needs for privacy and socialization with safety through Safety Risk Assessments and Environmental Safety Risk Level evaluations as described in the Behavioral Health Design Guide. Community crisis stabilization centers are legally recognized in only a handful of states and AHJs (Authority Having Jurisdiction) have not unilaterally established how these centers are evaluated.

Behavioral Health Care Center

Hospital Crisis Care Units | The Crisis Care Unit on a hospital’s campus is often within or adjacent to the hospital’s Emergency Department. Even so, it is separate from the ED, allowing the environment of care to be tailored to the needs of the patient population. Both staff and patients benefit from a space designed for the specific purpose of emergently treating mental health patients. Studies show that Emergency Departments can reduce costs with Crisis Care Units by avoiding unnecessary hospitalization and minimizing boarding – not to mention freeing up the ED and inpatient Behavioral Health beds.

Receiving acute patients to Crisis Care Units requires specific programming to support the patient and staff flow, while prioritizing an environment conducive to treatment and de-escalation.

Behavioral Health
Behavioral Health

Overall, the 988 roll out marks an exciting opportunity to reimagine mental health care in our communities. We expect Crisis Care Centers in the community and Crisis Care Units connected to an Emergency Department will emerge. Along with healthcare communities and designers, the AHJ will respond and adapt to new environments and lines for mental health care. The national 988 is the first domino to fall and could force other systematic care to fall in line with the demand for mental health treatment.

Resources

Behavioral Health Design Guide, Behavioral Health Facility Consulting, LLC.

Center for Health Design Webinar, D3 The Intersection of Diagnosis, Dignity, and Design for Mental and Behavioral Health Communities in Crisis.

Federal Guidelines Institute. Design of a Behavioral Health Crisis Unit

NAMI – National Alliance on Mental Health. “988 Reimagining Crisis Response

SAMHSA – Substance Abuse and Mental Health Services Administration “988 Partner Toolkit

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