Community Crisis And Emergency Services: Problems And Advantages

Revised:  November 27, 2013

In large population centers there is a growing use of emergency rooms, crisis centers, ERs, emerge-centers and crisis mental health triage centers to handle urgent and emergency problems.   Managed care organizations are contracting with community mental health programs, HMOs, insurance companies and public health plans to provide crisis services in large population centers.  The main purpose of these contracts is to pool resources and help insure there is an available and cost effective place for police, ambulances, families and friends to take people during a mental health crisis or psychological emergency. 

General Advantages Of Using Community Crisis Intervention Centers

  • Centralized Access To Medical Evaluation And Hospitalization Services.   Emergency problems are probably the main reason why Crisis, ER's and Triage Centers can be the best place to go.  Services are available 24 hours a day.  The facilities have the ability to evaluate, stabilize, hold and transport people to hospital, psychiatric and other evaluation facilities.
  • The Ability To Restrain And Hold Patients.  The ability to evaluate and hold people against their will for evaluations regarding potential dangerousness is a principle role of these centers.  Most people are brought to these centers by police or ambulance. 
  • Immediate Stabilization For Severe Problems.   Stabilization is the primary role of community crisis and emergency services.  This may involves education, providing information, problem solving, persuasion and medications.
  • Referral For Case Management And Follow-up Services.   The ability to provide follow-up services will vary with each ER, Emergi-Center and Crisis Triage Center.  Some have ongoing relationships with community mental health centers which may contract with them.  Some facilities are connected to their own managed care organization and to other organizations.

Potential Problems When Using Community Crisis Services

While there has been significant progress in making some emergency and crisis intervention services available, there are still serious problem areas.  Eight general problem areas are:

  • Negative Experience.  While they can be the best place to go for extremely serious problems, the  experience can feel strange to say the least, if not devastating and humiliating.  Many of these centers are overloaded, understaffed, inexperienced, poorly trained and provide services to an extremely wide range of clients that may include people who are restless, emotionally unstable, irritable, acting strange or bizarre, or being held against their will by the police.  These settings are often busy and the sheer pressure of working with so many highly distressed people can produce a degree of impatience or cynicism in some staff.
  • People Usually Want To Leave.  Convincing an adult or youth go to voluntarily, to cooperate, and to stay long can be difficult.  Many people who go to an ER, Crisis Center or psychiatric hospital want to leave at once.  They may express a desire to leave once they get there, after they wait a while or after they are admitted.   The reasons are usually simple.  The entire experience and environment is stressful.  It can be difficult or even impossible to hold a patient who voluntarily checks into a crisis or emergency center if they change their mind during or before the evaluation.  To hold an adult there must be sufficient evidence for a physician to hold the person.  Many youth are able to act normally once they arrive and can readily convince staff that serious problems described by parents do not really exist.
  • Gaps In Care.  There are tremendous gaps between the needs of the individual or family and the services offered by many managed care organizations and public funded crisis services. Funding for these services are often low in comparison to the demand and need. Crisis services are usually designed to serve a community and to be reimbursable as much as possible by health insurance and managed care companies.  Still, each crisis or emergency is unique and may require individual attention as well as a unique response to insure the best outcome.  
  • Rationing Services For Profit.  Crisis and mental health triage centers are increasingly run by businesses that make higher profits when fewer services are provided. Services may be rationed using "invisible" (unknown) and informal criteria driven by the organization's administrative and financial goals. These criteria can override professional judgment and recommendations.   Services are often organized around traditional services that include psychiatric hospitalization, residential treatment, outpatient therapy or medications.  The cost and impact of limiting and denying necessary services can be as high as 30% of the total health care cost. There is considerable argument that the cost of limiting services exceeds the cost of the services denied in many cases.
  • Emphasis on Emergencies.  Crisis and mental health triage centers focus primarily on emergencies that require immediate stabilization, symptom management, medication or hospitalization.  Crises and urgent problems, or problems that are not considered immediate dangers are often minimized and given inadequate follow-up care.  Minimization of a crisis can have a negative impact if a critical opportunity to intervene is lost.  The outcome of a missed intervention can be a diminished sense of importance and resistance to getting help in the future.  When people first acknowledge a crisis or ask for help, they may need comprehensive help.
  • Inadequate Follow-Up Care.  Referral to outside providers from a crisis or triage center is an uncertain process and depends on available county services, the insurance, as well as HMO or manage care companies involved.  In some cases there can be a complete lack of coordination, a failure to forward essential information to the professional taking the referral, and utter confusion when a crisis resurfaces before the first appointment. For the most part, follow-up care is limited to that which is available through country mental health services and authorized or provided by HMOs, or insurance or managed care companies. 
  • Excessive Focus On The Patient.  Unfortunately there are many aspects to a crisis and many people are usually affected by a crisis.  The consequences of a single individual in a crisis can have a significant impact on friends, families and loved one.   These people are in distress as well and may also need reassurance, praise, feedback and assistance to debrief their experience.  Some will need help developing plans to manage future problems or the possibility of acute relapse.  This level of support and service is generally not provided by hospital or crisis center based services.  Just because the services are not provided by managed care, or insurance or an HMO does not mean the service is not needed, not critical to resolve the crisis, or necessary to prevent  future crises.
  • Unclear Treatment And Intervention Standards.  Depending on the county you live in, your insurance, HMO or health care company, the benefits and the treatment you receive can vary tremendously. As evidence by the debates in state and federal government, it is a practice in many managed care, insurance and HMOs to deny services that you may be entitled to and for these organizations to compel  professionals to quietly support (or at least not protest) service delivery constraints which are based primarily on economic considerations.