Many EDs fill up with patients without serious medical concerns, but social or mental health problems clinicians may not be well-equipped to address. Putting social workers and other resources on scene to address these needs can expedite an appropriate response.
Another potential solution is to meet these patients where they are, eliminating the need for an ED visit altogether. In Denver, instead of sending an ambulance or law enforcement, some 911 callers in nonviolent circumstances will receive a visit from a mental health clinician and an EMT, a duo referred to as Support Team Assisted Response (STAR).
The idea for the STAR team grew out of a co-responder program in which a mental health clinician is paired with a police officer. Denver officials have been using this approach since 2016. Thanks to a partnership between the Mental Health Center of Denver and the Denver Police Department, STAR has grown to 32 responders.
When officials in Denver heard about CAHOOTS (Crisis Assistance Helping Out On The Streets), a program in Eugene, OR, that pairs an EMT with a mental health worker to respond to some calls, they saw an opportunity to add another layer to STAR. (See more about CAHOOTS here.)
“Running these calls with the Denver police [co-responder program] over the past several years, we really noticed that people call 911 for a variety of different reasons, some of which require a law enforcement officer, and some that don’t,” says Carleigh Sailon, LCSW, LAC, the program manager of criminal justice services at the Mental Health Center of Denver. “We really saw adding the STAR program as an additional response option ... that could be a force multiplier for the police and also [a way to] reroute calls that have historically gone to the police to a more appropriate team that can assist when the calls are more public health and resource in nature.”
CAHOOTS administrators assisted Denver officials in developing a decision tree to guide 911 dispatchers as to what type of response should be deployed. “They have been running [this type of response] in Eugene for 30 years,” Sailon observes.
The dispatcher asks callers different questions. Based on their answers, either the police, a co-responder team, or the STAR team will be deployed. For instance, Sailon, who serves on the STAR team, has responded to several mental health crisis calls.
“We can connect people with long-term services or reconnect them to their existing treatment team if they have one,” she says. “The clinicians in the van have a long history of working in the community on mental health, and can leverage the contacts they have made over their careers to connect people to the services they need mental health-wise in a kind of low-barrier, efficient way.”
There have been some STAR calls that resulted in a mental health hold. This can be based on the symptoms an individual is exhibiting and whether the person is suicidal or greatly disabled because of mental illness.
“Since we are licensed, we can initiate those [mental health holds] without calling the police,” Sailon explains. “If there is any sort of weapon or any sort of risk element present, [the dispatcher] would send a co-responder team. The police officer can work on team safety, while the clinician addresses the mental health crisis.”
Other STAR calls may involve transporting people to shelters or connecting them with treatment. Also, while the STAR team does not respond to any acute medical crises (e.g., an overdose), they occasionally encounter people with substance use problems.
“We partner pretty closely with our local syringe exchange, The Harm Reduction Action Center. We carry safe injection supplies on the van and portable syringe disposal so that we can give those out, and people can participate in syringe exchange,” Sailon notes. “We can also connect people to substance use resources, if they are looking for that.”
Build on Relationships
The EMTs on the STAR team can assess and triage any low-level medical needs. “We have redirected people either back to their primary care provider or an urgent care center when the ED isn’t necessary,” Sailon says. “We also get requested by ambulances quite a bit.”
Sometimes, an ambulance crew arrives, only to recognize there is no need for emergency medical care. “They will call STAR over so that we can route those [individuals] over to a more appropriate level of care,” Sailon shares. “We will take people to the ED if that is the level of care they need. We are really looking at connecting them to what is going to help them in the long run vs. just sort of funneling everything to the ED.”
A single STAR team approach has been running on a pilot basis since June 2020, Monday through Friday, 10 a.m. to 6 p.m. As of mid-March 2021, the STAR team had responded to 1,100 calls, and there was no need to ask for police backup in any of those cases. “There is definitely a need for more vans and more staff. We are hoping to get those rolled out this summer,” Sailon reports.
Those interested in pursuing a similar approach will find it easier if they already have a similar foundation on which to build. “We already had experience working with the 911 system, and we already had a strong working partnership with the police,” Sailon says. “About 30% of the time on our calls, it is actually an officer who shows up [on the scene] first, and then requests a STAR team to take over the call. [He or she] recognizes that it is not a law enforcement issue and is more appropriate for STAR.”
That collaborative history has driven the success of STAR. “We weren’t starting from square one in terms of building those relationships. I do think having a multilayered response system is important, not just having one option for people but having multiple options based on [whether] there is a risk situation, or if it is more of a resource call.”