911 what’s your emergency: police, fire, EMS — or mental health?

This article was originally published by San Antonio Report on August 15, 2021.

For decades, 911 operators have offered three options to callers on the line: police, fire, or emergency medical services.

But what if there was a fourth option? There soon could be in San Antonio.

Typically today, when law enforcement responds to a call involving a mental health crisis, they too often lack the expertise, time, or resources needed to fully address a person’s needs, experts say. This can result in unnecessary arrests and, in some cases, deadly use of force.

Now some departments are taking a different tack, sending licensed clinicians and emergency medical technicians (EMTs) out with law enforcement when calls likely involve mental health issues. Unlike traditional crisis intervention, these programs aim to be more holistic and get people long-term care.

The approach appears to be working. The Dallas Police Department, which launched such a program in 2018, has seen enough benefit, including reduced ambulance calls and more patrol officer hours freed up for higher priority calls, that it will double the number of multidisciplinary teams on the street.

Bexar County started a similar program in 2020 after a sheriff’s deputy killed a combat veteran who was experiencing a mental health episode. Similar to Dallas, Bexar County has seen promising results, expanding to two teams this year.

Now, the City of San Antonio is looking to invest about $4.8 million to establish a program of its own, part of its response to growing calls for police reform in the wake of the police murder of George Floyd in Minnesota in May of 2020.

‘We see everything’

Earlier this year, Sgt. Jennifer Wells of the Dallas Police Department responded to a call in which a 37-year-old man had struck his mother. Before 2018, he would have been arrested or taken to a hospital with an emergency detention order, Wells said.

But luckily for this man, who had limited mental capacity, the City of Dallas had that fourth option for 911 calls in place: the RIGHT (Rapid Integrated Group Healthcare Team) Care team, which deploys a police officer, paramedic, and licensed clinician to mental health calls.

Because a RIGHT Care team ultimately took the call, the man wasn’t treated like a suspect, he was treated like a patient, said Wells, who has been part of the program since it launched in South Dallas as a single-team pilot in 2018.

Today, five RIGHT Care teams cover the entire city, and the program will expand to 10 teams next year. Since it began, a spokeswoman with the department said, RIGHT Care teams have responded to over 4,600 calls, including crisis intervention calls, pro-active follow-up care, and visits.

It works like this: the police officer first assesses and secures the scene to make sure it’s safe for the EMT and clinician to proceed. They then talk with the person to see if they have any injuries, chronic illness, or history of mental health issues. Next, the team collaborates on how to proceed — typically avoiding an arrest or a trip to the emergency room, Wells said.

In the case of the man who hit his mother, it was obvious to Wells, the clinician, and the paramedic that he needed care a jail couldn’t provide. So the team worked overnight with police leadership to get the district attorney not to pursue charges. Instead, they worked to get him into a short-term care facility.

Every call is different.

“We see everything. … Everything from someone that is on drugs … to the very severe mental health issues where they’re not verbal,” Wells said. But no matter the scenario, she said, “Within 48 hours, we’re going to do a follow-up with that client.”

Does it work?

A dramatic increase in mental health calls led to Dallas’s program. The police department saw an almost 60% citywide spike in mental health calls from 2012 to 2015, with its South Central patrol district registering an even more dramatic increase of 85%, according to the Meadows Mental Health Policy Institute, which worked with the department to establish the RIGHT Care program.

“You want to apply a solution where there is a problem to be fixed,” said BJ Wagner, Meadows’ senior fellow of justice system policy. And clearly, there was a need in South Central Dallas for an alternative approach.

The Meadows Institute, a nonprofit think tank based in Dallas and Austin, aims to improve access to quality mental health services. It performed an analysis on Dallas’ 911 calls and its mental health care systems. It recommended deploying multidisciplinary response teams to just South Central, though at the time, city leaders wanted to deploy citywide.

a nearly 30% reduction in mental health calls to 911 requiring an ambulance, said Tabitha Castillo, the program manager.

“Without RIGHT Care, four officers would be [responding] to a mental health call,” Castillo said. “The average mental health call requires an average of 65 minutes per officer.”

When RIGHT Care teams respond, law enforcement officers are able to answer higher priority calls or go back to normal patrol operations, she said.

Dallas PD has saved the equivalent of over 1.5 full-time police officers, or 75 weeks of additional patrol time, since the inception of the program, Castillo said.

RIGHT Care also “decriminalizes mental illness,” she said. “Prior to the pilot program, Dallas police officers had few options other than [to] arrest individuals in crisis.”

Only 2% of RIGHT Care calls led to arrests and the repeat call rate is less than 7%.

Going deeper

“When we first began the rollout in Dallas, we had to the pump the brakes with our city partners a couple of times and resist that desire to do this program citywide,” Wagner said, in order to first prove the concept and establish the new system.

After a year with RIGHT Care, the South Central division saw

Bexar County’s Specialized Multidisciplinary Alternate Response Team (SMART) launched in October last year, after a sheriff’s deputy killed combat veteran Damian Lamar Daniels two months earlier.

“I guess you could say the deputies weren’t trained to handle something like this,” Bexar County Judge Nelson Wolff said. “A confrontation broke out and he was killed. … We all realized that was not the sort of team we should send out for a mental health call.”

The SMART program, funded by a $1.5 million allocation by Bexar County Commissioner’s Court, began as a partnership between the county’s Center for Health Care Services, Acadian Ambulance Service, and Southwest Texas Regional Advisory Council (STRAC), which administers the program. Just a few weeks after it was funded, the program launched with one team, working five days a week.

Existing collaborations made that speed possible, said Mike Lozito, director of Bexar County’s Office of Criminal Justice. The Bexar County Sheriff’s Office already worked with STRAC and area hospital systems on various mental health programs. SMART “just combined them all into a team that would go out and responds to calls,” Lozito said.

From October to June, SMART has responded to 378 calls, officials said.

Almost three-quarters of individuals involved in those calls became new patients with the CHCS, while 75 “were already established patients that we’ve been able to reconnect with,” said CEO Jelynne Jamison during a press conference last week.

So far this year, CHCS has linked 25 new patients to its own outpatient services and 67 to other local providers for mental health or substance abuse services, Jamison said.

Deputies who encounter the SMART team in the field “like it because it’s not putting them in a circumstance that they don’t know how to address,” said Lozito.

Law enforcement officers are traditionally trained to resolve a call and “move on to the next one,” he said. These teams get to “go deeper” into the situation and get to the root causes of the 911 call.

The program’s success has allowed it to grow. This month, the sheriff’s office added another team to respond more quickly to calls within the donut-shaped service area that surrounds the City of San Antonio and includes suburban cities.

Keys to success

Follow-up visits have been one key to success in both Bexar County’s and Dallas’s programs.

SMART certified peer support specialists, provided by CHCS, follow up with patients in Bexar County and help them navigate hospital and assistance systems, make doctor appointments, fill prescriptions, or connect them to other resources such as housing. Some of these peer specialists have had their own mental health issues, said Lozito: “They can interact with individuals and say: ‘Hey, I’ve been there.’”

Making sure other law enforcement officers and the community are aware of these mental health resources is another critical component for success.

It took a little bit of time for the community and for other police officers to know that they could ask for the RIGHT Care team, said Wells of the Dallas PD.

“The other officers in the city needed to know that we existed,” she said. “We gave out pamphlets to let them know what type of calls to call us to, what meets the RIGHT Care criteria. And then we told them the benefits of calling RIGHT Care. After we did that, we could tell that it was catching on [because] more officers were calling us.”

Some residents in need have even shown up to police stations looking for the RIGHT Care teams, she said, because they have seen the team helping others in their neighborhoods.

This year, police officers on RIGHT Care teams stopped wearing their uniforms. Instead, they wear polos and khakis “for a more approachable, less intimidating attire when interacting with the community,” Castillo said.

SMART team members in Bexar County also opted out of formal uniforms. The Dallas and Bexar County teams also both drive unmarked vehicles.

“We wanted to have the soft approach,” Lozito said.

Some programs in other cities, such as Eugene, Oregon and New York City, have taken an even softer approach, removing police entirely out of the equation for many mental health calls, sending unarmed clinicians, EMTs, and/or social workers.

Addition, not subtraction

Sheriff Javier Salazar said sending teams without law enforcement doesn’t make sense in Bexar County.

“I’ll just come out and say it: for starters … we’ve got a lot more guns present in the state of Texas than in other parts of the country,” Salazar said at the press conference.

The multidisciplinary response teams do not replace the need for law enforcement’s presence, Wagner said.

“We acknowledge police will never be replaced when it comes to the aspect of responding to mental health emergencies,” she said. An officer needs to be there to “ensure that those responses are safe for the civilians” who are sent to help, the patient, and the surrounding community.

“Another interesting demographic that we have, that may be different than other parts of the country is we’re Military City, USA,” Salazar said.

Many veterans suffer from mental illnesses such as post-traumatic stress disorder, he noted.

“It’s not their fault,” he added. “We owe it to them to take care of them.”

San Antonio’s program under development

The San Antonio City Council is expected to allocate the money for SAPD’s pilot program as part of its 2022 budget, which it will vote on in September. It’s also looking to re-direct lower-priority 911 calls to other departments, such as Animal Care Services, the fire department, and code enforcement.

After Daniels was killed, SAPD Chief William McManus issued new protocols for how officers respond to calls involving people who may be mentally ill.

Police Chief William McManus issued a special order for mental health-related calls for service. Credit: Scott Ball / San Antonio Report
Instead of approaching that person first, officers contact the person who made the call or anyone else who can give the responding officer more context for the situation “so that we don’t confront that [mentally ill] person cold … and it ends up with someone losing their life,” McManus said at the time.

The chief’s special order also allowed officers time to contact the SAPD Mental Health Unit, Crisis Intervention Team, social workers outside the department, or other resources.

The proposed new pilot program will go further. Like Dallas, the City of San Antonio hired the Meadows Institute to produce recommendations on how SAPD could better handle mental health calls.

The Meadows team started in San Antonio by looking at data and the cross-section between criminal justice and behavioral health systems,” said Wagner.

They reviewed call data and identified hot spots that accounted for most of the city’s mental health calls. Researchers found calls with the greatest level of intensity and public safety needs occur most often in the 78207 zip code, which includes the near West Side and small parts of downtown.

San Antonio’s inventory of mental health programs and collaborative partners — from SAPD’s Mental Health Unit to STRAC’s Program for Intensive Care Coordination — gives the city a solid starting ground, Wagner told City Council committee members last month. “There’s a lot of momentum toward integrated services and having a really good team approach.”

But in order for the multidisciplinary teams to be successful, local access to walk-in clinics, hospital bed capacity, and supportive housing need to be enhanced, she said.

“We want to make sure that we’re not just responding to crises,” Wagner told the San Antonio Report last week. “It’s easy to create a crisis response team. People do it all the time, we’ve been creating crisis response teams for 25 years. And we’re still doing it because it hasn’t worked. What we have to do is we have to create a medically-facing crisis prevention system, that breaks the crisis cycle.”

Meadows recommended a targeted program that would send teams to cover at least two zip codes five days a week.

Instead, San Antonio’s multidisciplinary teams will start by covering the entire Central police substation’s territory, which includes downtown and much of the near west and north sides, seven days a week. Two shifts will cover approximately 16-20 hours a day, answering mental health-related calls.

Deputy City Manager María Villagómez estimated that a team would be in the field as soon as March or April next year and will be modeled after the RIGHT Care program.

“This program is not totally new to us,” she said, noting the police department’s collaboration with STRAC and the fire department’s Mobile Integrated Healthcare Program that sends clinicians out with EMTs. The Meadows report also recommends having a licensed clinician in the 911 call center.

Program details will be worked out if City Council approves it next month, Villagómez said. “We have work to do in terms of coordinating with other partners within our community like the Center for Health Care Services [and] STRAC as we are launching this program.”

The $4.8 million proposed for the program includes $4 million for the San Antonio Metropolitan Health District to hire 34 city positions and funds to partner with other agencies. Some of those funds will be used for the city’s response to domestic violence, but details weren’t yet available.

The rest will be used for SAPD overtime to staff the two new shifts and to the fire department for EMT staff.

“Mental Health will be [the team’s] primary responsibility; they may address other calls like [domestic violence] and substance abuse, Villagómez said in an email. “Those individuals may be homeless.”

Because of her experience in Dallas for more than three years, the San Antonio Report asked Wells if she had any advice for the Alamo City’s team.

She suggested team members participate in a team-building activity. “You have to have that team component for it to truly, truly work. I’m not saying everybody has to be best friends … [but] it really got us over huge hurdles in the beginning.”

The full article is available online here.