City of Alexandria, Virginia
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MEMORANDUM
DATE: FEBRUARY 3, 2021
TO: THE HONORABLE MAYOR AND MEMBERS OF CITY COUNCIL
FROM: MARK B. JINKS, CITY MANAGER /s/
DOCKET TITLE:
TITLE
Proposed Alexandria Crisis Intervention and Co-Responding Program.
BODY
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ISSUE: Creation of a Police-Behavioral Health Co-Responding Program.
RECOMMENDATION: That City Council: (1) receive and endorse the proposed Alexandria Crisis Intervention Co-Responding Pilot Program proposal; and (2) direct the City Manager to proceed with implementation as outlined in this memorandum.
BACKGROUND: This memorandum and recommendation are the next steps in response to City Council’s June 23, 2020 request for information on 21st Century Public Safety Models, as well as, Council’s discussion at its October 27, 2020 Legislative meeting on policing and behavioral health issues.
In 2009, City staff began implementing an array of services aimed at identifying, assisting and diverting persons with behavioral health challenges away from the criminal justice system and into the treatment system. In addition to the 24/7 crisis response work conducted by DCHS Emergency Services staff, hundreds of police officers and other first responders have been trained in crisis intervention, learning how to identify persons experiencing a behavioral health crisis, how to de-escalate situations, and how to safely and appropriately connect these persons with treatment resources. In addition, services have been developed to proactively reach out to persons not in crisis but who are high utilizers of emergency services, including 911 and the Inova Alexandria Hospital Emergency Department, to connect them with community treatment services that decrease their need for reactive, crisis-based interventions.
Other initiatives which promote compassion, prevention and treatment services to persons in crisis and/or already involved in the criminal justice system include the Alexandria Treatment Court, the Police Diversion Program in Detox, Forensic Discharge Planning and ReEntry services from the Adult Detention Center, the Commonwealth Attorney’s Office Mental Health Initiative, Community Release planning through the Magistrate’s Office, the CORE program which partners mental health staff and probation staff, response and outreach to survivors of an overdose, and many others. Initiatives have been created and implemented for many years, largely with State grant funding, that focus on prevention, intervention, treatment and follow-up at every intersection point between behavioral health and criminal justice, all aimed at helping persons lead healthy, productive, law-abiding lives in the community; Alexandria has long been recognized as a leader in the State with these efforts.
In June 2020, the Alexandria City Council requested information on alternative approaches that prioritize non-law enforcement responses to homelessness, public gatherings, after-hours construction, noise, and other quality of life complaints; and the creation of a mobile crisis unit trained in crisis prevention and management such as suicide prevention and intervention, domestic disputes, substance abuse, and other mental wellness calls. In response to this request, staff presented a review of current services that target these challenges during the October 27, 2020 Council meeting. As a result of that presentation, staff were directed to craft a proposal to create a Co-Responding Crisis Intervention Program.
PROPOSAL:
The Alexandria Crisis Intervention Co-Responding Program (ACORP) is a pilot program intended to examine the effects of a co-responding crisis response approach with persons experiencing a behavioral health crisis and examine use of City staff in these efforts. The program will pair a specially trained behavioral health professional and specially trained police officers to respond to calls for service involving a behavioral health crisis or concern. This team will respond to calls together with the shared goals of diverting persons experiencing a mental health crisis away from criminal justice settings and into treatment settings when possible, resolving calls without use of force, promoting entry into the least restrictive treatment environment, minimizing unnecessary emergency department visits, and evaluating and comparing outcomes of this approach to those achieved by existing City services to better inform any opportunities for future growth.
The team will utilize best-practice, trauma-informed approaches that aim to maximize helpful and safe outcomes for persons served, decrease the stigma often associated with behavioral health calls for service, promote opportunities for racial sensitivity and equality, and deliver services in ways that de-emphasize law enforcement as the first response to persons in need of behavioral health assistance while still maintaining safety for all involved.
Goals of the Pilot:
• Maximize safety for all involved;
• Collect and analyze data and outcomes; compare outcomes of ACORP with existing crisis response services;
• Connect persons in crisis with appropriate behavioral health treatment services;
• Minimize unnecessary arrest of individuals experiencing a behavioral health crisis;
• Minimize potentially negative encounters and/or injuries for persons experiencing a behavioral health crisis;
• Minimize unnecessary visits to the Inova Alexandria Hospital Emergency Department for the sole purpose of a mental health evaluation; and
• Identify strengths, opportunities and any necessary resource needs or changes for future programming, as well as position City services for the eventual implementation of State-directed crisis response initiatives, as further described below.
Program Design:
Initially, ACORP will respond to calls Monday-Friday, 12pm-8pm. Available Alexandria Police Department (APD) call data reveals that while there are no obvious and significant days and time of days when the majority of behavioral health calls are received, it does appear that a slightly higher percentage of calls come in on weekdays versus weekends and overall, slightly more calls seem to come in during the afternoon and evening hours, though fluctuations are quite small and are considered coincidental. The operating hours of 12pm-8pm have been chosen simply as a starting point; if ACORP data reveals that changes to these hours are needed over time to best serve the community, adjustments will be made.
A team of dedicated staff, one behavioral health clinician (Therapist Supervisor) and one behavioral health police officer from the APD’s Behavioral Health Unit, will respond together to calls regarding persons in need of a behavioral health crisis intervention in the City. Calls for behavioral health crises received outside of these forty hours each week will be handled via the City’s existing crisis response structure.
Referrals to ACORP can be made in a number of ways, including: through identification at dispatch of a person in need of behavioral health assistance, through a call already in progress in which an APD officer recognizes that the call involves a person with behavioral health needs, through calls to DCHS Emergency Services in which staff determine that a call should be referred to ACORP, etc.
The ACORP team will be primarily located at the Alexandria Police Department, will respond to calls in “soft” clothing (eg, CIT polo shirts), and will utilize an unmarked police vehicle to respond to all calls.
A DCHS Therapist Supervisor will serve as the day-to-day Program Manager of ACORP and will report to the DCHS Emergency Services Team Leader. The APD Behavioral Health Unit officer will report to the Sergeant of the Behavioral Health Unit at APD. Team members will work in tandem on calls. While ACORP calls will be responded to by two staff, one from DCHS and one from APD, a second APD officer will be on or near the scene in case back-up support is needed. When possible, this second officer will be a member of the APD Behavioral Health Unit.
While the team has many goals, high among these must be safety for staff, the person in need of assistance, and the community. As such, each call for service will begin with a safety and risk assessment of the scene by the APD Behavioral Health Unit officer. If the scene is determined to be a low safety risk, the intervention will be led by the DCHS Therapist Supervisor who will conduct a behavioral health assessment and determine recommended next steps. The ACORP team members will necessarily work closely with existing City services, including Emergency Services, CITAC, Homeless Services, Substance Use Treatment, Outreach and Engagement, and Fire/EMS when on-site medical assistance is needed.
Because ACORP is a pilot program, the approach to service delivery must be flexible and nimble. For example, if data indicates that the hours of service should be adjusted to better align with community need, the service will pivot its hours accordingly. Because outcome data for behavioral health calls currently handled by APD are not yet available, it is not possible to more precisely structure the design and focus areas of this team, nor know completely at this time what the full resource need will eventually be. As such, the initial design of ACORP may change once the pilot program is up and running and as outcomes are analyzed; ultimately, the goal is to help ensure that the program is providing the most targeted, specific and helpful interventions possible.
Prior to the proposal to establish ACORP, City Council approved funding to hire a data analyst with a specific focus on behavioral health interventions and outcomes. This position in the City’s Office of Performance Analytics (OPA) will focus on services that intersect the behavioral health and criminal justice system, including CIT, CITAC, the Alexandria Treatment Court, and 911 trends, etc as well as on prevention, intervention and outreach strategies. Findings will ultimately help shape the future development of the program based on data.
ACORP IMPLEMENTATION STRATEGY:
Phase 1/Planning and Program Development:
The initial phase of ACORP will focus on hiring and training the team members, as well as the creation of protocols, policies and a data analysis framework that will guide the work. Protocols to be developed/considered include:
• Criteria to determine how to identify calls that prompt a referral to ACORP, and which calls will be responded to by Fire/EMS and or APD alone
• Workflow/call assignments: how calls are routed to ACORP from DECC, Emergency Services and others
• How the on-scene response will occur (eg, how is safety assessed and maintained, etc)
• Identification of any changes needed to current DCHS and APD policies, MOUs, etc
• Staffing plans (eg, how to manage when one team member is on leave, what back-up staff could be utilized, etc)
• What work team members will engage in when not responding to a crisis calls (eg, visiting areas of traditional high need including homeless shelters, homeless encampments, etc)
• Referral protocols (eg, transport to CITAC, referral to Outreach and Engagement, CSB Intake, Detox, etc)
In addition, data elements to be tracked must be identified, as does a mechanism to collect, share and analyze the data. Significant assistance from the OPA analyst and a contracted Program Evaluator will be needed. Baseline data regarding how crisis calls are responded to currently must be gathered so that comparisons can be made that will help inform future planning.
Team members will jointly participate in a comprehensive training program focused on a number of critical areas, including:
• Racial and Social Equity
• Cultural Diversity and Sensitivity
• Trauma-Informed Care
• Crisis Intervention and De-escalation
• Assessment of Special Populations/Needs
It is anticipated that Phase 1 will take three to six months from the date funding is allocated to create the pilot. A planned expedited position creation, classification and recruitment of the DCHS Therapist Supervisor will be aimed at decreasing this time. APD intends to transfer an existing officer into the Behavioral Health Unit and this person will serve at the primary ACORP police officer.
Phase 2/Implementation, Management and Reporting:
At the completion of Phase 1, ACORP will launch and begin responding to behavioral health calls. Data will be collected throughout, and monthly reports will be created that include data analysis, successes, challenges, resource gaps, and lessons learned. Sanitized, confidential summaries of cases will also be included to allow for a richer understanding of the types of calls handled by the ACORP staff, as well as the outcomes for persons served. Data management and the overall evaluation of ACORP outcomes will be led by a contracted Program Evaluator.
Meetings between DCHS and APD management will occur at least monthly and serve as an opportunity to monitor the program, address any challenges, problem solve, and support the team members.
ACORP staff will join the Alexandria Behavioral Health Alliance (ABHA) so that services can be integrated with the many existing City initiatives aimed at diverting persons with behavioral health challenges away from the criminal justice system. ACORP data will be included in the larger data collection and analysis initiative to be led by the OPA Behavioral Health Data Analyst.
In addition, a presentation on ACORP will be folded into the City’s current Crisis Intervention Team 40-hour training, as well as through regular in-service trainings at both DCHS and APD so that all staff are aware of the program and how it can be utilized.
Phase 3/Next Steps:
Data and outcomes will be measured throughout the course of the pilot through a contracted Program Evaluator. Monthly reports will be created, as well as an annual report. Approximately six months after the program launches (Phase 2), an interim report will be presented to City Council that will include preliminary outcomes and any associated recommendations. A mechanism to solicit community and client feedback will be created and serve to inform any needed changes.
Staff anticipate significant changes at the State level related to behavioral health crisis response, resulting both from the newly adopted Marcus Alert Legislation and also, from the implementation of the crisis step under STEP-VA. It is not known when these changes will affect Alexandria but having an existing co-responding crisis service in place will allow us to more easily and quickly integrate any mandated changes into our service system. These State changes, coupled with our own local analysis of ACORP outcomes and other shared behavioral health/law enforcement initiatives, will help determine next steps in the evolution of behavioral health crisis response in Alexandria.
Staffing:
The ACORP pilot will be staffed with one Therapist Supervisor from DCHS, who will serve as the Project Manager. This staff will partner with one Behavioral Health Police Officer from APD’s Behavioral Health Unit and together, this small team will provide crisis response coverage in the community from 12pm-8pm, Monday through Friday. Back-up coverage for the DCHS Therapist Supervisor will be provided by DCHS Emergency Services staff and back-up coverage for the APD officer will be provided by other behavioral health police officers from APD’s Behavioral Health Unit.
A racially diverse, multilingual team is preferred for ACORP staffing, as are staff with a demonstrated history and commitment to working with persons with behavioral health needs. Team members must demonstrate not only the knowledge, skills and abilities to do the work but also a passion, flexibility and commitment to make a difference.
ACORP staff should be dedicated to the program so that teamwork, relationships and trust can be built and solidified. Building a new team and service delivery system requires the demonstrable and full commitment of both agencies and cannot be best achieved if approached in an ad-hoc way; conducting co-response crisis interventions should not be folded into the work of current staff under an “other duties as assigned” approach.
The following staff are needed for the ACORP pilot:
a. 1 FTE Therapist Supervisor at DCHS (new position):
a. Position will serve as the Program Manager and be responsible for overall program management, including protocol and policy development, research on best practices, creation of a data management system with the OPA Behavioral Health Analyst and Program Evaluator, etc
b. Must be a certified Emergency Services Prescreener
c. Will report to DCHS ES Team Leader
d. Must have knowledge, skills and abilities that support the assessment of special populations, including persons who have developmental disabilities, youth, older adults and persons with cognitive disabilities
e. Position could eventually supervise additional staff if the program expands over time, and/or the CIT Coordinator
b. 1 FTE Behavioral Health Police Officer at APD (existing position):
a. Officer will be part of the APD Behavioral Health Unit; ACORP is one of a number of initiatives that will be managed by the APD BH Unit
b. Must be CIT Officer
c. Will report to Sergeant of the APD Behavioral Health Unit
Data/Outcome Measures:
Fundamentally, this pilot must answer the question: does a co-responding approach help address any identified challenges that currently exist in the City’s behavioral health crisis response system? To answer this question, significant baseline data must be gathered and an approach to capturing new data and outcomes for ACORP must be designed. As such, the expertise of a Program Evaluator will be key component of the pilot.
As a best practice for a new pilot program, a Program Evaluator will be contracted for a one-time outcome evaluation of the pilot. This would involve initial work to help design the program at its start and later, analyze and report the program results. The Program Evaluator would work closely with the Office of Performance Analytics to design program enrollment processes as well as data collection needs. Strict data sharing agreements would be put in place to protect the personal information of program participants and in alignment with City Administrative Regulations. Periodic status reports on the data collection would be expected. The evaluator would be responsible for data collection and cleaning as well as writing the final reports of the program results at the agreed-upon end of the pilot period.
The implementation of a pilot project will allow staff to determine whether improvements in particular outcomes can be achieved via this alternative approach and what future programming may be needed to ensure that City residents receive the most effective, compassionate, safe, racially and culturally sensitive crisis response services possible. In addition, the implementation of a pilot program will allow City staff to be well-positioned when new State initiatives (Marcus Alert System, STEP-VA) are eventually mandated.
While specific data elements to be tracked need to be identified and managed under the expertise of the Program Evaluator, measures to be captured and analyzed will likely include:
• Number of calls received by DECC
o Number/Percent that are BH calls
o Number/Percent of calls responded to by ACORP
• For ACORP interventions:
o Source of call (person, family member, call for service in progress, CSB Emergency Services, other professional, community, other)
o Time and day of the week
o Duration of response
o Location of call
o Presenting problem, including any known substance use
o EMS response needed?
o Demographics: Race/Ethnicity/Gender/Age/Address
o Housing status
o CSB status (open, closed, not known to CSB)
o Prior law enforcement involvement?
o Outcomes
§ Transfer to CITAC
• Emergency Custody Order (ECO) to Temporary Detention Order
• ECO to release from custody
§ Referred to 24/7 non-hospital care (Detox, Crisis Care)
§ Preventable hospital admissions
§ Preventable discretionary arrests
§ Arrest
o Use of force/injury
o Comparison of ACORP interventions to non-ACORP interventions
FISCAL IMPACT: In order to implement the co-response program as discussed in this memorandum, the addition of one full time Therapist Supervisor at an annual cost (salary and benefits) of $125,000 plus a program evaluator whose work would be contracted for at an estimated cost of $50,000. In addition, there would be $9,400 in non-personnel funds needed tor training, IT costs and other items. The total initial cost of this program would be $184,400. This is addition to the Data Analyst position approved by Council on October 27. These costs are planned to be incorporated into the Proposed FY 2022 Operating Budget to be presented to Council on February 16, but with the process to hire this new position starting immediately after Council authorizes this new co-response program.
It is possible that additional staffing will be proposed once this program has been initiated and had some time to determine what the workload and demands are. Staff set the initial staffing level based on wanting to learn first from actual experience, and then be able to adjust later to a higher staffing level if the initial program’s workload and demands indicate additional resources are warranted. Staff’s judgement at this point (but without supporting data) is that if additional resources are needed, this could include the addition of one clinical position (Senior Therapist) at an additional cost of $119,000, which would allow the program to expand an additional 40 hours a week, including the potential to staff overnight hours. If Council is interested in starting this co-response program with a higher level of staffing than proposed, the forthcoming FY 2022 budget add-delete process would be the mechanism to make that decision.
STAFF:
Debra Collins, Deputy City Manager
Michael L. Brown, Chief, Alexandria Police Department
Don Hayes, Deputy Chief, Alexandria Police Department
Kate Garvey, Director, Department of Community and Human Services
Renee Gordon, Director, Department of Emergency and Customer Communications
Liz Wixson, Director of Clinical and Emergency Services, DCHS
Gabriel Duer, Emergency Services Team Leader, DCHS
Carol Layer, Assistant Adult Services Director, DCHS
Beth Murdock, Performance Analyst, Office of Performance Analytics
Courtney Ballentine, Acting Captain, Community Relations Division, Commander, APD
Dana Wedeles, Special Assistant to the City Manager’s Office