My ongoing involvement with the annual Behavioral Healthcare Design Showcase—and a trip earlier this year—gave me an opportunity to visit the CPSA/Pima County Crisis Response Center in Tucson, a design that won top honors in the 2011 Design Showcase. And, while our annual Showcase program honors the efforts of architects and designers involved in behavioral healthcare, we all know that design is but one of the elements needed for success.
The Crisis Response Center is the product not only of great design and execution, but of one community’s efforts to do the right thing and do it well. Plans for the $18 million CRC and the neighboring $36 million Behavioral Health Pavilion at University Physicians Hospital in southern Tucson were funded through two voter-approved bond issues that joined a local transportation bond issue on the ballot for the county’s special election in May 2006.
2005: Problems in search of a solution
By 2005, years of rapid growth had pushed Tucson toward a significant milestone: a population nearing one million citizens and recognition as a major US city. But with growth came challenges: an overtaxed road and transport network; increasing rates of crime, arrests, and incarcerations; a growing problem with methamphetamine and street drugs; and an overstressed hospital system considering how to keep pace with local growth. One hospital system in particular, University Physicians Hospital (UPH) was considering plans to address a regional shortage of inpatient psychiatric beds.
As CEO of CPSA, the Community Partnership of Southern Arizona—the managed behavioral health organization, or MBHO, contracted with the Arizona Department of Health Services Division of Behavioral Health services to administer behavioral healthcare in the Pima County area—Neal Cash had shared his views on the region’s challenges with local officials for years. But in 2005, he sensed that local officials—county supervisors, the county administrators, the county bond committee —were open to ideas on a new scale: the city was gaining more national attention almost every day.
So, he asked them some big questions: “Are we big enough now to warrant a psychiatric crisis care center?” “Would you be open to CPSA leading an effort to develop concepts for a center?” When they agreed, he then asked if they would consider placing an additional bond issue before voters, on a May 2006 ballot, to fund it.
“Amazingly, they agreed. I got a very positive response. They encouraged me to pursue the concept for a facility,” he recalls. The facility would have to meet a range of needs:
· divert many psychiatric emergency or crisis cases from emergency departments at hospitals
· divert adults from jails and juveniles from the detention system into care
· combine multiple medical disciplines
· engage consumers and families as part of the workforce
· Most critically and importantly, would engage people at the point of crisis—people with or without other medical benefits—to get them crisis psychiatric care but then to reintroduce them into the community-get them back to their lives, families, work, and relationships in a more integrated and effective way.
After a proposal was developed, there was a public hearing to consider whether the crisis center concept should be placed on the ballot. The response was overwhelming—over 500 citizens attended that meeting. County supervisors voted the measure—now called the Crisis Response Center— onto the ballot unanimously. At the same time, they approved placing another bond issue measure before voters that would support UPH’s expansion plans, now called the Behavioral Health Pavilion.
After both of these bond issues were approved by strong margins in the May 2006 election, Cash and his CPSA team headed into the project’s toughest phase, which was “staying on track with the vision we had for what this facility should look like between the time the bonds passed and the time that we broke ground in September 2010. While we (CPSA) were involved in every phase, there were a lot of other entities involved as well. And, when a project is publicly funded, there is lot of scrutiny, too.”
Thankfully, project plans and finances were well advanced when the nationwide recession hit in 2008. The recession had two major impacts: On one hand, the recession-driven slowdown in construction led to lower bids and lower-than-anticipated construction costs for the project, which broke ground in September 2010. On the other hand, Cash said that the recession caused “an erosion in funding—particularly for continuous care—along with a greater demand for services in the community.”
Why voters went along
How, one wonders, were local voters convinced to support the center?
Cash explains. “I was speaking throughout the community—at hospitals, Kiwanis clubs, with law enforcement, all sorts of people. Through those conversations, I could see that there were a few things that really appealed to local people.”
1) Mentally ill people shouldn’t be in jail. “People understand that those who are mentally ill don’t belong in jail and that it makes sense to get people care in the right setting. They realized that this would save precious law enforcement resources for where they were really needed.”
2)Those in psychiatric crisis shouldn’t be in hospital ERs, either. “I presented to local hospital officials and suggested that if there were a more appropriate place to provide care for people in psychiatric crisis, their EDs wouldn’t be so crowded with people who shouldn’t really be there,” Cash recalls. He adds that “since a significant number of the mentally ill are also uninsured or homeless, caring for them in a crisis response center could cut hospital expenses for uncompensated care. And, that is a problem in nearly every community.”
3)Our community can do better—and it should. Cash also found that, “there was a feeling that, as a community, [having this center] would really raise the bar on the quality of life in Tucson,” he recalled. “It was not at all a partisan issue.”
Even then, it took a while to really convince many local leaders that the CRC would make sense for Tucson. “For some of them, it was ‘We’ve heard all this before. We’ll believe it when we see it,’” he says.
The CRC site
The location of the new Crisis Response Center was found in the course of talks with local hospital officials, who suggested that the CRC be sited next to UPH’s proposed Behavioral Health Pavilion. The new Behavioral Health Pavilion would be added to the UPH facility in southern Tucson, while the CRC would be built adjacent to the Pavilion. (See photo gallery for all illustrations)
Between the two buildings, which were linked by a secure, enclosed walkway, would be an emergency transport area. On one side , civilian ambulances would arrive on a looping driveway at the UPH emergency room, which was built onto the side of the new Pavilion. On the other, reached by driving around the CRC building, was a secure “sally port” for use by police vehicles transporting detainees.
The sally port area, which consists of a parking area enclosed by structure on three sides and a movable fence/gate on the fourth (see Figure 3), opens into secure check-in spaces at the back of the CRC, and into a secure entrance at the branch office of the Pima County Court. At the court, a judge can hear mental health court, drug court, and competency cases involving individuals being treated at the CRC.
Key elements of the CRC design
1) Two points of entry: The CRC offers two points of entry, the public “front door” and the secure “sally port” for individuals who have been detained by law enforcement yet who require care. To meet accreditation requirements, the walk-in “front door” traffic is separated at the reception desk, with adults flowing into a nearby waiting area linked to the adult treatment side of the facility, and pediatric cases (children and families) directed into a separate waiting lined to the pediatric wing of the facility. (See photo gallery)
A similar pattern is used for individuals entering the sally port. Each is checked through a secure waiting room then directed to a secure evaluation room. After evaluation, juveniles and adults flow into their respective “23-hour” treatment areas.
2) 23-hour observation/triage areas. Both the adult and youth areas are configured in a very flexible manner to allow for wide swings in the levels of consumer traffic, which tends to peak on weekends. 23-hour patient couches, separated by curtains, are arranged as needed in the open areas opposite the nurses’ stations in both the adult and children’s areas. Family and small group meeting rooms are available along the hallways to allow for private evaluations or visits.
3) Short-term adult residential treatment. Adults who need care beyond 23 hours proceed first to a 15-bed adult short-term sub-acute treatment area, which is located directly upstairs. This area offers more intensive treatment for periods of three to five days.
The short-term sub-acute treatment area features a spacious day room, a nurses’ station with floor-wide visibility (see photo gallery), 15 patient rooms, and an open-air deck. The inpatient rooms are compact and plainly equipped; one cost-saving safety measure is that each contains a small half-bathroom (lavatory and toilet only), separated from the patient room by a curtain (See Figure 5). Patients who want a shower must use a separate shower room located on the main hallway.
The CRC does not offer short-term sub-acute beds for children. When the CRC was designed, the original plan was to refer these children out to available inpatient beds in the surrounding community. However, in light of the closure of some of these beds since 2008 and longer than expected stays for some young people requiring stabilization, Cash says that this decision is under reconsideration.
4) Telecommunications center—A call center, located on the second floor, atop the youth assessment area, was always envisioned as a kind of community resource, says Cash. The space, which is equipped with 48 computer and telephone equipped cubicles and a number of overhead display screens, offers great flexibility (see galllery) Daily, only a few of the cubicles are required for network dispatchers to handle all telecommunications traffic in the care network: each call is triaged receives a recommended disposition.
To meet other needs, however, the call center can be configured to house everything from safety forces coordinating the response to a community emergency, to the staff of a regional or statewide suicide hotline, to a group of mental health peers manning a regional peer-support center where local consumers can call in to talk. The latter, says Cash, “we see as a preventive service to help those who are not yet in crisis, but who need to speak with a peer.”
5) Administrative, staff, and provider spaces—Adjacent to the call center on the second floor are offices for CRC managers and staff, as well as spaces to allow for co-location of staff from various community providers and agencies.
6) An adjacent sobering/detox facility—“One thing we didn’t want was to see our CRC services overwhelmed by law-enforcement referrals or self-referrals of intoxicated people,” Cash explains. “So, we opened the detox facility even prior to opening the CRC. The goal was to create a safe place for them to detox and then, hopefully, to get into longer-term treatment. ” Like the CRC, the detox facility offers a fast, secure law-enforcement drop off area.
Performance vs. projections
Because facilities like Pima County’s Crisis Response Center are unique, there’s no instruction manual for building them. Thus, the estimates of adult and youth patient traffic, in particular, were just that, says Cash who notes, “The only way to get a feel for the flow –the quiet times vs. the busy times—is to actually do it for a while.”
While six-month results for the youth treatment area have been a little bit lower than anticipated so far, Cash reports that “the results on the adult side have been amazing.” Once the community realized that there was a single number to call for help – even if the help needed fell short of a crisis – things really took off.” On average, in its first six months of operation, the CRC has handled:
· Crisis line calls received – 61,154 total; 8,736 monthly average
· Adults served to date – 4,918 total; 703 monthly average
· Youth served to date – 776 total; 111 monthly average
While traffic in the youth space has been lower than initial projections, Cash says that “We’re in dialogue with the juvenile justice system, considering ways that we can route kids away from detention, get them into treatment here, mediate their crisis, and get them back home or back to school. While the legal folks have the final call, they do agree that a lot of kids just don’t need to be in detention and could benefit from a healthcare model like this one.”
Because the staff required to operate the CRC can be costly, Cash says that CRC managers and staff have coordinated to reduce costs by being flexible, responding to fluctuations in census by shifting staff resources throughout the CRC as needed. Another important strategy is full inclusion of some of the area’s 200 trained peers, who work as recovery support staff. “These are the people, working at all levels as mentors, coaches, case managers, and in other roles, that make the CRC much more than a psychiatric urgent care center,” says Cash.
He adds that peers engage and support consumers during treatment, then reconnect after treatment to follow up and help consumers navigate the care system. They can also offer support and help to frequent users of the system by engaging them in methods for avoiding future crisis episodes.