Tucsonans struggling to access mental health treatment will soon have a new option regardless of their ability to pay, through the Crisis Response Center's upcoming expansion of urgent care services.

The expansion comes in advance of July's nationwide designation of "988" as the new three-digit dialing code that will route callers to the National Suicide Prevention Lifeline. The lifeline is a 24/7, free and confidential support line for people in distress and those who care for them.

The Crisis Response Center anticipates an influx in people looking to be connected to services due to the simplification of the nationwide helpline.

The center will also launch a transitions program for people needing post-crisis care.

Experts say the national and local demand for mental and behavioral health services is on the rise, accelerated by the increasing opioid epidemic and the ongoing toll of the COVID-19 pandemic.

Tucsonans often wait more than a month to access nonemergency mental health or behavioral health services, so the expansion will fill a sizable gap and provide critically needed care, the Crisis Response Center's operators say.

Leveling up
to meet needs

In Tucson there is a five- to six-week wait to see a psychiatrist and in Phoenix the wait time extends up to three months, said Colin LeClair, CEO of Connections Health Solutions.

Connections has been managing and staffing the Tucson Crisis Response Center since 2014.

The Crisis Response Center, next to Banner-University Medical Center South, 2800 E. Ajo Way, opened in 2011, designed to be a one-stop hub for comprehensive, coordinated care for people experiencing crisis.

The county invested in the capital costs of the building and the annual operating costs of the services are financed via health care funds, so there is no ongoing cost to the county, LeClair said.ย 

The crisis center is staffed 24 hours a day, 365 days a year, and offers a range of recovery-focused services for adults, teens and children experiencing mental-health or substance-use-related crises.

"We started with the people that needed the care the most. The people that tend to get refused everywhere else," said Dr. Margie Balfour, Connections Health Solutions' chief of quality and clinical innovation.

Today, the center accepts everyone, including people who are psychotic, intoxicated and a danger to themselves or others, who are often turned away from other behavioral health providers and instead taken to jail, Balfour said.

Two case managers, a behavioral provider and a technician listen to a client inside a room at the Crisis Response Center. Officials at the center believe their urgent care expansion and transitional services will be up and running by midyear at the latest, coinciding with the nationwide implementation of 988, the suicide-prevention dialing code.

Instead of taking people to an emergency room โ€” where they might languish in the waiting room for hours โ€” or to jail โ€” when the crisis isn't truly a criminal justice issue โ€” first responders can take them to the Crisis Response Center.

There, the patients will be kept for a 23-hour observation period. In that time they will be assessed, will have access to social workers and psychiatrists, and, if necessary, will receive medication or treatment.

"There are lots of folks for whom the emergency department is definitely not appropriate, but even the crisis center isnโ€™t appropriate, it's just better than a hospital," LeClair said. "Maybe you don't need a 23-hour observation stay, but what you do need is care now in a therapeutic environment with a professionally trained team who understands you."

Connectionsโ€™ founders created the observation model 30 years ago to give patients a better alternative than the emergency room. Connections itself was founded in 2009, giving high-risk patients an immediate solution with the ultimate goal of keeping them out of hospitals and getting them connected with community-based care and access to services.

"They were doing the right thing 30 years ago, and that model is now what we call value-based care. Investing in patient outcomes while helping avoid more costly and inappropriate settings," LeClair said.

Value-based health care incentivizes providers to focus on the quality of services rather than the quantity. Under a value-based model, providers, including hospitals and doctors, are compensated based on their patients' health outcomes.

Connections and the Crisis Response Center are now focused on creating better access for not just the high-risk population, but for patients who have an urgent need but aren't able to find psychiatric care.

"The more levels of care you have, the better match to their needs and outcomes," Balfour said.

Patients can write messages on the walls within a courtyard at the Crisis Response Center.

'They were calm,
they were helpful'

Located around the backside of Banner-University Medical Center South and next to the Abrams Public Health Center, the Crisis Response Center looks more like an upscale law firm or advertising agency than a place where one would go to receive treatment for mental or behavioral health issues.

With its sprawling, dark-colored glass windows and angular edges, the building is impossible to miss, but easy to mistake for something else.

The lobby is open and inviting,ย filled withย natural light, and an open-air courtyard sits in the middle of the square-shaped building.

While the building is highly secure, it doesn't bear the usual telltale signs. Law enforcement and paramedics have a separate, secure entrance around the side, for easy entrance and exits. The idea was to make it faster for police to drop a person off at the crisis center than to book them into jail, Balfour said.

Tucson police Sgt. Jason Winsky, who oversees the Police Department's Mental Health Support Team, said the expanded services will not only help people needing services, but also officers, who are often the first point of contact for a person in crisis.

"We also know a crisis isn't always a moment in time, in fact, quite frequently it's something ongoing in a person's life," Winsky said. "So even if you go anywhere from the crisis center to a vacation to get away from your problems, when you get home, your problems are still there."

Data shows that another crisis is likely to occur and that crises often occur in groupings, meaning police are seeing the same person being taken to the Crisis Response Center multiple times in the same month.

"There needs to be an intervention for that person to break the cycle," Winsky said. "It's that three- to five-day window when a person comes back to the community that we worry about an event happening."

Captain America on the all of a youth room at the Crisis Response Center.

The two-story facility houses the crisis center on the ground floor, with separate waiting areas, triage, exam rooms and observation units for adults and youths.

Suicide is the second leading cause of death for middle- and high-school-age youths in Arizona, shows data recently released by the U.S. Centers for Disease Control and Prevention. Nearly 21% of Arizona high school students surveyedย in 2019 said they had seriously considered suicide in the last 12 months, according to the CDC.ย 

The second floor of the building holds call takers for the local crisis line during nonpandemic times and an inpatient unit for people who need to stay past the 23-hour observation period.

There is a walkway from the ground floor directly to Banner South, which holds the county's 66-bed inpatient psychiatric facility.ย 

Margie Balfour, chief of quality and clinical innovation, talks about the urgent care area at the Crisis Response Center.

The crisis center staff includes social workers, psychiatrists,ย nurse practitioners, peer support specialists, case managers and patient care techs. There are no security guards in the unit, but patient care techs and other staff members are trained to keep a close eye on patients and to check in and engage with them often.

The observation units are open spaces with recliners that can lie flat, should a person wish to sleep. There are some partitions between recliners, for patients who want privacy, but all the seats are visible from central staff workstations, which gives nurses, techs and others a 180-degree, fishbowl-style view of the unit.

On a recent Friday afternoon, a dozen people were in the adult observation unit, many resting or sleeping in their recliners. Two techs were out in the unit, talking to one of the more agitated people, but the scene remained quiet, calm and controlled.

"I never wanted to go there, but if I had to go again, I would want to go there and nowhere else," a man named Kyle said of his visit to the crisis center. "I have never been in a medical facility with a nicer staff. They were calm, they were helpful, and they tried to do their best for every single patient. Thatโ€™s pretty awesome. It means they love what they do."

Another former patient, Lacey, echoed those sentiments.

"I'm so glad I came here," she said.

Finite resources

Another benefit of a value-based model such as the Crisis Response Center's is that clinical and fiscal goals are closely aligned, Balfour said. It's less of an expense to taxpayers for people to be doing well in the community and engaging in outpatient care, rather than cycling through the justice system or hospitals, she said.

"In the mental health field right now there are finite resources. State budgets arenโ€™t growing, so we're going into this assuming there are not more dollars and resources coming. Weโ€™re on our own," LeClair said.

At the crisis center, it doesn't matter if a person has private insurance or no insurance. The center accepts everyone and will get patients signed up for the state's Medicaid program, the Arizona Health Care Cost Containment System or AHCCCS, if needed. If a person isn't AHCCCS-eligible, Arizona Complete Health, as the Regional Behavioral Health Provider, is the payer of last resort.

Because private insurance doesn't pay for emergency psychiatric care, the center is able to use safety net taxpayer funds โ€” a mix of mostly Medicaid and other federal funding, along with some state and local funds โ€” to cover the costs for privately insured individuals. LeClair referred to a bipartisan bill in Congress, the Behavioral Health Expansion Act, that would fix this disparity and fund more crisis care across the board, using Arizona's system as a model for the country.ย 

There are 15 single in-patient rooms at the Crisis Response Center.

"No one is charged. There's no cost," Balfour said. "Arizona guarantees everybody that if you're on Arizona soil and you have a crisis, you're entitled to the first 24 hours of crisis care services."

From there, the Crisis Response Center staff will work with patients to figure out coverage options, but no one goes untreated.

Urgent care services have always been available at the center, but on a much smaller scale, Balfour said.

Patients can get prescriptions refilled, see a therapist, meet with a peer or join a group, with most services available 24/7, LeClair said.

"It's providing access however they need it so they don't decompensate while waiting for a visit (with an outpatient provider)," LeClair said. The psychology term "decompensate" refers to losing the ability to maintain normal or appropriate psychological defenses, sometimes resulting in depression, anxiety or delusions.ย 

The center's transitional services will provide post-observation care for people who have completed their 23-hour stay, as well as for patients who come through the center's urgent care portion.

"Crisis doesn't flip off a light switch just because it's 22 hours and 59 minutes and you're told to navigate the health care system like you're not in crisis," Balfour said.

With a four- to six-week wait for outpatient visits, it simply isn't tenable to discharge a person from their observation stay and leave them to figure out the next steps, LeClair said.

"Itโ€™s a really complex system to navigate," LeClair said. "We're trying to set them up for success so they donโ€™t have to keep using our services."

Repairing cracks
in the system

LeClair hopes the Crisis Response Center will lead by example and show others that it's not only possible to create an appropriate, cost-effective, therapeutic level of care, but also to thrive under such a model.

He and Balfour are readying the center for its expanded services by increasing staffing and reconfiguring spaces. When everything is done, the center should have the capacity to serve between 400 and 600 extra visits a month, on top of the 800 to 1,000 adults who already visit the center each month.

At Phoenix's Urgent Psychiatric Center, which is also run by Connections, the transitions program began in November 2018, with the focus on decreasing hospitalizations for people with repeat visits who weren't engaged in outpatient care. Upon intake, 49% of participants were homeless, but Connections was able to secure safe housing for 95% the same day either in halfway houses, specialty shelters, residential programs or by coordinating with family and friends.

Also upon intake, less than half reported having contact with a primary care provider, but after their time in the program, 30% transitioned to outpatient primary care while 60% transitioned to community-based behavior health clinics.

in Tucson, Crisis Response Center officials believe the urgent care expansion and transitional services will be up and running by midyear at the latest, coinciding with the nationwide implementation of 988.

"A three-digit mental health crisis line has the potential to give people a lot more access to care, but if you're asking an operator for help, there needs to be something past the phone call," Balfour said.ย 

A newly heightened focus on caring for one's mental health brought awareness to the need and created momentum for change, LeClair said.

"Maybe some of the silver lining of the COVID experience is it really exposed the cracks in the system and now there's the attention and support to fix it."

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Caitlin Schmidt is the Star's solutions reporter, focusing on potential approaches or solutions to social issues and problems. Contact her at 520-573-4191 or cschmidt@tucson.com. On Twitter: @caitlincschmidt