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Crisis Intervention Response Team Six Month ReportCrisis Intervention Response Team (CIRT) Six-Month Report CITY OF BOULDER C IRT 2021 December 2021 CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORTi Executive Summary_____________________________1 Analysis_____________________________________3 Outcomes___________________________________12 Next Steps___________________________________14 More Information______________________________15 Appendices_________________________________16 Table of Contents 1CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT Executive Summary The Crisis Intervention Response Team (CIRT) is composed of four licensed behavioral health clinicians in the city’s Housing and Human Services Department (HHS) embedded with the Boulder Police Department (BPD). CIRT clinicians respond with police on calls involving behavioral health crises that come through BPD dispatch. Behavioral health includes mental health and substance use disorders. The City of Boulder has funded behavioral health co-responder clinicians since 2016, previously through the Mental Health Partners’ Early Diversion Get Engaged (EDGE) program. In 2021, the city increased its annual investment from $142,000 to $587,000 to build on EDGE efforts by transitioning from a contracted program to hire clinicians as city staff, forming CIRT. Development of CIRT further integrates co-response with broader efforts of HHS and BPD to support vulnerable community members. 2 CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT EXECUTIVE SUMMARY This report is a summary of the first six months of CIRT operation, from early February to early August 2021. Highlights of the first six months include: Needs for program adjustments will be further examined as more data becomes available with a longer period of CIRT implementation. The city will continue to provide annual updates on CIRT. CIRT clinicians initiated involuntary mental health holds in about 5% of calls. One of the benefits of CIRT expertise on behavioral health calls is the reduction of unnecessary involuntary commitments, which lessens negative impacts to people by preserving their autonomy, and reduces unnecessary utilization of Emergency Medical Services (EMS) and emergency departments. 5% Of the 523 encounters including CIRT during this time period, about 0.4% involved use of force by an officer. 0.4% Six (about 1%) of the 523 CIRT encounters involved an arrest. 1% Approximately 25% of 309 unique clients had more than 1 encounter with the CIRT team in this 6-month period, with the top 10 high utilizer clients interacting with the CIRT team an average of 7 times in 6 months. 25% CIRT responded to 523 calls for service, with an increasing response trend which appears to be related to both increased utilization of CIRT and increased demand – some of which may be impacted by seasonal trends. About 1 in 4 CIRT encounters involved a person experiencing homelessness. Another 8% involved an individual at risk of losing housing. Demand data indicate that overall CIRT program hours are well matched to hours when the service is needed in the community. CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT 3 Analysis About the Data Data from the first six months of program operation includes some limitations, which should improve over time. • The CIRT team recently worked with a vendor to develop a long- term data system customized to team needs. In the interim, CIRT has been using a temporary system with significant limitations. This has resulted in some areas of missing data which the program hopes to report on in the future. In some cases, certain data elements are only available for a subset of the 523 CIRT responses. • The CIRT team has had some periods of vacancies during the first six months, which has limited calls CIRT can respond to, impacting service numbers. Nationally and locally, the field of behavioral health is experiencing staffing shortages, and crisis work is a specialized area within behavioral health that frequently presents recruitment challenges. • There are inherent difficulties with collecting data from people in crisis. At the time of CIRT interaction, many people are simply not in a position to answer numerous questions about themselves. Although the team has a protocol for follow up calls with residents after the initial crisis, some people are difficult to reach on follow up or have a variety of reasons they don’t wish to offer further information about themselves. 4 CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT Analysis Response Trends CIRT responds when dispatched by the communications center or requested by a police officer. CIRT can also assign themselves to a call in instances where they are familiar with the person involved or otherwise recognize that there is a behavioral health component. • The team responded 523 times to calls for service during the first six months of the program. This number does not include follow up calls made by the team after initial contact. • Utilization of CIRT on calls with a behavioral health component increased significantly in the first few months of implementation as demonstrated in monthly totals of calls responded to by CIRT in Figure 1. Figure 1 CIRT Unit Responses by Month 0 20 40 60 80 100 120 140 37 Feb. 54 Mar. 76 Apr. 116 May 115 Jun. 125 Jul. 5CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT Analysis Figure 2 Keyword Calls for Service by Month • Monthly data was also analyzed based on calls for service where the caller mentioned a keyword or phrase indicating a behavioral health component (Figure 2), suggesting that the call might be appropriate for a CIRT response. Boulder Police responded to 1,344 calls using these key words during the first six months of CIRT implementation. This represents 3% of all BPD calls for service (39,115) during this period. These calls demonstrate a more variable trend than CIRT responses during the first six months, indicating an increasing use of CIRT independent from call volume trends. • Reasons for differences between the number of calls including behavioral health key words and the number of CIRT responses are discussed in the section below examining trends by time of day and day of week. Call trends may also be impacted by seasonal factors. Anecdotal clinician data indicates that summer months are typically busier times for crisis work. • The majority of initial contacts with clients are face to face. Follow ups with clients are sometimes done face to face, other times by telephone. 213 228 214 209 237 243 190 200 210 220 230 240 250 Feb.Mar.Apr.May Jun.Jul. 6 CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT Analysis Call Volume: Time of Day, Day of Week CIRT seeks to align service with highest volume times for behavioral health calls. Service hours for CIRT as currently designed are: Mon. - Fri: 8 a.m. to 10 p.m. Sat./Sun.: 10 a.m. to 8 p.m. During the first 6 months of program implementation, there were periods of time when regular program hours had to be reduced due to vacancies or new clinicians in training. Figure 3 displays the total number of calls during each hour of different days of the week in the first 6 months when analysis of key words in dispatch data indicates the call may have been appropriate for CIRT response. For example, during the first 6 months, there were a total of 20 calls (about 3 per month) during the 8 pm hour on Thursdays that would be candidates for CIRT response. Overall, CIRT hours as currently designed, match well with high volume times for crisis calls to BPD. Figure 4 demonstrates the number of calls the CIRT team responded to by hour of day and day of week during the first 6 months of program implementation. There are several reasons for the difference between the 1344 calls considered appropriate for CIRT response, and the 523 calls responded to by CIRT. 1. Reduced hours during vacancies or training periods decreased CIRT availability to respond to some calls. 2. During this initial implementation period, some referrals to CIRT may have been missed due to ongoing work on improving referral protocols with dispatch, as well as revisions to police policies and procedures on utilizing CIRT. 3. At times CIRT clinicians were unable to go to calls if they were already deployed on another call. 4. 422 calls matching key words for CIRT response fell outside of planned CIRT hours. This means an average of approximately 2 calls per day fell outside of regular CIRT hours. A frequent question is whether CIRT should be a 24/7 program. Hiring overnight clinicians to handle 2 calls for each 10-hour shift may not the best use of resources. This is particularly true because clinicians are already difficult to recruit for daytime shifts, and would need to be paid a premium to work overnight. An additional supervisor may also be needed for overnight shifts and these clinicians would not be able to do some tasks – such as follow up calls – that daytime/ evening clinicians currently do. This raises the question of whether the large amount of resources required to staff the program 24/7 could be used in a more effective way to support community behavioral health. As more CIRT data is collected, HHS and BPD will monitor trends to determine needed changes to staffing. Some current trends suggest an additional clinician may be needed during peak hours during the week. 7CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT CIRT Unit Responses by Day of Week/Hour of Day Total for Feb-July 2021 Figure 4 Figure 3 Incidents w/CIRT Keyword by Day of Week/Hour of Day Total for Feb-July 2021 DAY TIME OF DAY (MILITARY TIME)GRAND TOTAL000102030405060708091011121314151617181920212223 Sun.6 8 2 5 3 3 4 5 4 5 6 4 8 12 12 10 10 10 13 12 11 8 12 8 181 Mon.5 2 1 4 3 3 7 12 12 5 10 8 5 11 12 11 8 13 19 11 12 11 3 188 Tues.4 3 5 2 3 2 6 3 7 12 8 6 14 14 9 11 10 7 6 9 12 8 9 10 180 Weds.7 6 4 5 4 2 6 2 7 13 16 9 9 9 10 7 9 9 13 8 13 10 10 5 193 Thurs.5 5 5 4 6 3 3 7 7 16 11 9 15 10 10 10 15 11 9 9 20 17 9 8 224 Fri.6 3 7 7 5 4 3 6 13 9 10 11 8 12 9 15 12 12 6 8 7 6 5 10 194 Sat.8 2 10 3 2 3 2 4 12 5 11 10 14 10 10 3 7 7 9 12 8 11 13 8 184 GRAND TOTAL 41 27 35 27 27 20 27 34 62 72 67 59 76 72 71 68 74 64 69 77 82 72 69 52 1344 DAY TIME OF DAY (MILITARY TIME)GRAND TOTAL05060809101112131415161718192021 Sun.1 2 1 7 5 11 2 3 3 2 37 Mon.1 2 6 6 8 9 11 8 10 9 8 7 85 Tues.2 2 7 7 12 5 6 7 12 10 7 9 1 87 Weds.1 10 13 16 9 14 11 12 10 11 5 112 Thurs.2 3 15 4 8 7 16 7 14 11 5 5 1 1 99 Fri.1 1 5 9 10 7 8 8 7 7 6 6 3 2 80 Sat.2 2 2 3 1 1 5 6 1 23 GRAND TOTAL 2 1 4 15 50 44 55 46 61 56 57 55 40 32 4 1 523 8 CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT Analysis Most Common Types of Calls Receiving CIRT Response The most common dispatch category resulting in a CIRT response was welfare checks, which include checking on persons affected by mental illness. Further description of these call categories is included in Appendix A: Dispatch Call Category Descriptions. BPD is in the process of refining dispatch categories to better distinguish between calls requiring behavioral health assistance and other “welfare check” calls that do not always require the level of service provided by CIRT. These updated categories are anticipated to be operational by December 2021 and will enable better reporting in the future. Figure 5 Top 10 Dispatch Categories with CIRT Response Who Does CIRT Serve? CIRT assists a wide variety of people in the City of Boulder. Age: The median age of CIRT clients during the first six months was 38 years, with a range from age 9 to 91 (Figure 6). Gender: Of the 440 clients who reported a gender, roughly 54% identified as male, 42% female, 3% transgender or non-binary. Race/Ethnicity: see Figure 7. 0 50 100 150 200 250 Number of CIRT ResponsesWelfare Check Disturbance Follow Up Medical Phone Message Assist Walk In Report Trespassing Other AgencyAssist Other 230 36 36 26 19 13 9 9 35 12 9CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT 9CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT Figure 6 CIRT Team Encounters by Age Figure 7 CIRT Team Encounters by Race/Ethnicity 0 0-11 years 12-17 years 18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75+ years Age not reported 20 40 60 80 100 120 2222 5050 109109 8181 7171 5252 2525 1515 59 44 55 302302 1616 4499 1717 133133 White Asian Other / 2 or more races American Indian / Alaskan Native Black Hispanic / Latinx Unknown / Missing 10 CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT Analysis Housing Status: The majority of people CIRT responds to have some type of housing in the community. Although people that are unhoused represent about 1 in 4 CIRT responses, they are over-represented in crisis response as it is estimated that less than 1% of the overall city population is unhoused. The role of stable housing in behavioral health crisis is also notable as an additional 8% of CIRT encounters involved people at risk of losing housing. Although a direct link between housing crisis and behavioral health crisis cannot be proven through CIRT data, clinicians report anecdotally that a behavioral health crisis can precipitate housing loss. In cases where individuals were seen multiple times by CIRT during this time period, housing status was recorded each time, reflecting 488 housing status entries for 306 unique individuals in Figure 8. People who are living in a shelter, motel, or vehicle are considered unhoused. An example of a situation included in the “Other” category would be someone who has unstable housing due to domestic violence, someone living in a treatment facility, and someone in custody of the Department of Corrections. People with multiple CIRT Encounters: • 25%, or 77 of 309 unique clients, had more than 1 encounter with the CIRT team logged in this 6 month period. • The top 10 high utilizer clients interacted with the CIRT team an average of 7 times in the 6 month period. CIRT works with clients, as well as a wide variety of related community service providers, to connect people with ongoing community supports. However, some individuals have a combination of serious mental health and substance use issues that make it very difficult to consistently engage in non-emergency care. In addition, care for some situations – such as methamphetamine use – is limited and not always easy to access for all populations. Finally, it is extremely difficult for people without stable housing to concentrate on any type of mental health treatment or substance use recovery, as the basic need for housing and associated stressors will typically overshadow other needs. Figure 8 Housing Status 0 50 100 150 200 250 300 350 303 41 123 18 3 Adequate Housing At Risk of Losing Housing Unhoused Unknown Other 11CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT Analysis Primary Concern – Types of issues faced by residents interacting with CIRT Community members seek assistance for a wide variety of behavioral health situations, with some people experiencing multiple concerns. 40% of encounters, or 195 clients, had a concern related to a behavioral issue, developmental disorder, or situational crisis. Over one-third of clients had trauma, anxiety, or personality or delusional disorder indicated. The least frequently cited concern for CIRT encounters were medical issues, Traumatic Brain Injury (TBI), or medication. More information on the terms in Figure 9 is included in Appendix B: Primary Concern Terms. Figure 9 *Clinicians could indicate more than 1 primary concern, so data adds to more than the 488 sample Primary Concern at Time of Encounter*Figure 9: Primary Concern at Time of Encounter 0 50 100 150 200 195 40 155 128 117 107 96 Behavioral Issue, Developmental Disorder, Situational Reaction Trauma, Anxiety, Personality Disorder, Delusional Disorder Alcohol/Drug/Meth Intoxication or Withdrawal, Aggression Information, Other Suicidal Ideation or Attempt Hypomania, Mania, Psychosis Medical Issue, TBI, Medication Current Care Status CIRT talks with residents about care needs. 30% of residents interacting with CIRT reported that they were already receiving behavioral health services from a provider; 24% of clients reported not receiving any behavioral health services yet; 3% reported being in the process of obtaining behavioral health services. Due to data and process issues, current care status is not available for the remaining 43% of those receiving CIRT services. 12 CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT12CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT CIRT refers residents to a variety of community resources and ongoing treatment options. In some cases, people have an immediate need for further treatment, including being admitted to a hospital emergency room, or accessing the walk-in crisis clinic/detoxification facilities operated by Mental Health Partners. The team also tries to connect people with ongoing community treatment and other support resources (e.g. foodbanks, homeless services, etc.). Many non-emergent referrals are done as part of follow up calls because people are not always able to engage in conversations about follow up care while experiencing a behavioral health crisis. In some cases, people do not wish to participate in follow up discussions or cannot be reached for follow up. Figure 10 displays the distribution of referrals where this data is available for CIRT contacts. Outcomes Figure 10 Types of Referrals after CIRT Intervention 360 Total Referrals 72%72% 3% 25%25% 258258Referral to Ongoing Treatment 8989Immediate need for further treatment (e.g. ED, Walk-In Crisis Clinic, Detox) 13Other (e.g. declined, unable to contact) 13CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT 13CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT v Mental Health Holds ɖ CIRT clinicians initiated involuntary mental health holds in 24 instances (about 5% of calls) during this six-month period. One of the benefits of CIRT clinical expertise on behavioral health calls is the reduction of unnecessary involuntary commitments, which lessens negative impacts to people by preserving their autonomy, and reduces unnecessary utilization of EMS and emergency departments. Use of Force and Arrests ɖ Of 523 encounters including CIRT during this time period, two (or about 0.4%) involved use of force by an officer. In one instance, an individual attacked a CIRT clinician and was taken to the ground by an officer. No weapons were used and the individual was not injured. In the other instance, an individual who expressed intent to “suicide by cop” and feigned use of a weapon was tased. ɖ Six (about 1%) of the 523 encounters involved an arrest. Facilitating Return of First Responders to Service ɖ CIRT facilitated return of Fire/EMS to service 31 times (6% of interactions). This low percentage may be related to a lower number of CIRT calls involving Fire/EMS. ɖ CIRT facilitated return of police to service 154 times (29% of interactions). In general, CIRT clinicians arrive to calls separately from officers. Some CIRT shifts during the initial six-month period involved “ride along” hours, when a dedicated officer was paired for a shift in a car with a CIRT clinician and could not be returned to other service. These shifts may have impacted “return to service” data. Dedicated officer hours, grant funded during this period, are generally considered beneficial as they result in CIRT going on more calls, getting to residents more efficiently and building relationships/cross-training between officers and clinicians. The city has applied for additional funding for dedicated officer hours through multiple federal funding opportunities. CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT14 The city will continue annual reports about the CIRT program, with the goal of continuous improvement of available data, including outcome data, and the ability to compare trends or changes over time. The city has also applied to federal sources for funding to support an independent evaluation of the program by professional research consultants. As the CIRT program continues, the city will assess opportunities to expand CIRT capacity or implement other complementary programs as indicated by community needs and broader regional work to support behavioral health for local residents. It should also be noted that crisis intervention is one part of a broader spectrum of mental health and substance misuse prevention and treatment needs supported by the city and other regional partners. Next Steps 15CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT More Information about CIRT How can I access CIRT? ɖ To request a response from CIRT, please contact 911 in an emergency, or the non-emergency dispatch line: 303-441-3333. Please note that CIRT always responds with police. ɖ For a routine inquiry related to the program, you can reach CIRT at 303-709-4291. Because of the nature of our work, this number is not always monitored, but we will return calls within 24 hours. What other resources are available for behavioral health crises? ɖ Colorado Crisis Line: 1-844-493-8255 or text TALK to 38255. ɖ 24/7 Walk-in Crisis Center & Addiction Services at 3180 Airport Road. ɖ Mental Health Partners’ non-police mobile crisis response team: 303-447-1665 16 CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT Appendix Appendix A: Welfare Check is a category used when police are requested to check on a person for various reasons. Some examples are an elderly person who hasn’t been seen for several days and their vehicle is home, a person who has communicated ideations or threatened suicide, a relative has been unable to contact a family member in a reasonable amount of time, a person observed to be delusional or exhibiting behavior out of the ordinary. Dispatch Call Category Descriptions Assist is a call category used for persons requesting general assistance. Some examples are answering questions about policing and/or laws, or providing a ride to someone. Disturbance is a category used for confrontations and physical fights not involving weapons, including individuals acting erratically in a disturbing or violent manner. Follow Up is a category used when a caller needs to add information to an existing report. It can also be used by dispatch when an officer or CIRT advises they are working on an existing report or previous call. Medical is a category used for all situations that require an ambulance response. This includes persons suffering mental health episodes. Other is a category used when the situation does not fit in any other existing call category. Outside Agency Assist is a category used when an outside agency requests police assistance. This includes home checks and standbys requested by Adult and Child Protective Services. Phone Message is a category used when someone requests a specific officer or resource call them for reasons not associated with a call for service. These are usually administrative in nature. Trespassing is a category used when a person enters or refuses to leave the private property of another person or entity. Walk In Report is a category used for persons who walk in the Public Safety Building lobby to request assistance or report a crime. 17CITY OF BOULDER | CRISIS INTERVENTION RESPONSE TEAM (CIRT) SIX-MONTH REPORT Appendix Appendix B: Medication refers to situations where the person calling is identifying that they need assistance getting their medication or they are having a crisis related to side effects of current medications. Primary Concern Terms Behavioral issue describes issues with emotional regulation resulting in behaviors that are disruptive or otherwise incompatible with the person’s current environment. This could describe behaviors at any age, but often applies to children and adolescents. One common scenario would be an outburst related to rules or boundary setting. Situational reactions are behaviors or actions arising from a specific event. For example, this could refer to someone experiencing transient suicidal thoughts following the end of a relationship. Information captures situations where the team receives clinically significant information from collateral sources (police, family, other treatment providers). Developmental disorders (aka neurodevelopmental disorders), neurocognitive disorders (including traumatic brain injury), personality disorders, and delusional disorder are used here as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5). A distinction in our categorization was made between Traumatic Brain Injury (TBI) and other neurocognitive disorders involving what is colloquially known as dementia and neurodegenerative diseases such as Parkinson’s and Huntington’s Disease. Hypomania and mania are used here as defined in the DSM 5 and refer to episodes within the diagnostic framework of bipolar I or bipolar II disorders. Psychosis is an umbrella term that describes hallucinations and delusions, as well as the essential characteristics of a thought disorder such as schizophrenia. Psychosis can be present in multiple diagnostic presentations, including major mental illnesses, as well as substance use disorders.