In Phoenix, Arizona, which has a comprehensive crisis response apparatus as well as a CIT program, dispatchers in the Phoenix Police Department (PPD) Communications Bureau can refer eligible 911 calls to Crisis Response Network (CRN), a nonprofit organization providing crisis call center services across the state.^[]Crisis Response Network, “About Crisis Response Network,” accessed September 9, 2020, https://www.crisisnetwork.org/.... In Phoenix and the wider Maricopa County area, CRN’s Central Arizona crisis line resolves many crises over the phone or, if an on-scene response is appropriate, sends a mobile crisis team (MCT) of clinicians trained in crisis intervention rather than police.^[]Crisis Response Network, “Services,” accessed September 9, 2020, https://www.crisisnetwork.org/.... Phoenix is also piloting a co-response approach that pairs officers with MCTs for crisis-related calls that prompt a police response but nonetheless indicate a need for behavioral health assessment and de-escalation.^[]Paul Galdys, deputy CEO, RI International, and Sabrina Taylor, CIT training coordinator, Phoenix Police Department, March 4, 2020, telephone call.

This case study describes how Medicaid funding in Arizona supports Phoenix police collaboration with crisis care providers to connect more people to treatment, including a co-response pilot and efforts to divert crisis-related 911 calls to the crisis system rather than sending police.

Ensuring a well-funded crisis care continuum

The funding of crisis care in Arizona has roots in a decades-long lawsuit settled in 2014. Arnold v. Sarn alleged that the Arizona Department of Health Services and Maricopa County had failed to sufficiently fund a comprehensive community mental health system as required by state statute. The settlement of the case secured the guaranteed provision of community-based services and programs for people with serious mental illness. Arizona is now unique in how it braids local, state, and federal funding sources to ensure a broad range of community-based services are widely accessible and meet the settlement’s standards.^[]Christine Vestal, “‘Arizona Model’ for Behavioral Health Crisis Care Gains Attention from Other States,” azcentral, February 21, 2020, https://www.azcentral.com/stor...; Shelley Curran, director of crisis, cultural, prevention, and court services, Mercy Care, September 8, 2020, email.

The lawsuit’s legacy has important implications for collaboration between police and behavioral health partners. According to Paul Galdys, deputy CEO of Maricopa County behavioral health care provider RI International, the partnership between law enforcement, the Regional Behavioral Health Authority, and Arizona Medicaid has created the expectation that “crisis providers, including mobile crisis teams and our crisis facilities, [must] say ‘yes’ every time we get a referral.”^[]Galdys and Taylor, March 4, 2020, call. Galdys described the positive result of this expectation as a “no wrong door” approach for people with mental illness. Designated drop-off areas for law enforcement help facilitate swift handoffs between police and crisis care providers, encouraging officers to continue bringing people in crisis to appropriate facilities rather than the emergency department, or even jail.^[]Vestal, “Arizona Model,” 2020. PPD’s partnerships with these facilities are among the program elements that set the department’s CIT efforts apart from those focused solely on training for police. Crisis care providers, meanwhile, do not have to worry about the type of health care coverage someone has when they arrive at their door because of Arizona’s braided funding approach.^[]Shelley Curran, director of Crisis, Cultural, Prevention, and Court Services, and Tenasha Hildebrand, crisis and veteran services administrator, Mercy Care, April 29, 2020, telephone call.

The service delivery expectations that emerged in the aftermath of Arnold v. Sarn, paired with Arizona Medicaid’s managed care approach, have amounted to significant funding for CRN, whose Central Arizona crisis line and 27 mobile crisis teams (MCTs) operated by other local providers give Maricopa County comprehensive mobile crisis response capacity.^[]Galdys and Taylor, March 4, 2020, call. Tenasha Hildebrand, crisis and veteran services administrator at Mercy Care, a managed care organization that helps fund CRN, underlined the success of crisis lines in referring people to care outside of the crisis system without the need for an on-scene response altogether, and the significant majority of situations CRN manages are stabilized over the phone.^[]Curran and Hildebrand, April 29, 2020, call; Crisis Response Network, “About,” database (Tempe, AZ: CRN), https://www.crisisnetwork.org/.... However, for crisis-related calls that come through 911, 911 dispatchers now work with CRN to ensure these situations do not receive police responses by default.

Within this group, about 150 MCT dispatches per month result from police referrals after officers have arrived on-scene and determined that one of CRN’s mobile teams can help de-escalate a situation and provide transportation to appropriate crisis services.^[]Galdys and Taylor, March 4, 2020, call. If PPD decides a mobile team is needed, CRN has agreed to deliver one within an hour—and without the standard screening process that might slow down a response. CRN’s average response time is in the range of 30 to 45 minutes.^[]Matthew Moody, manager of Contact Center Operations, Crisis Response Network, June 18, 2020, telephone call.

PPD and CRN have explored opportunities to integrate CRN’s mobile crisis teams with 911 dispatch to reduce the time required for an MCT to arrive on-scene. In early 2020, a co-dispatch pilot program began serving a specific Phoenix neighborhood among those that have seen the highest volume of CIT calls.^[]Ibid. When a 911 call in that neighborhood includes a behavioral health issue but also requires a police response, 911 dispatchers simultaneously notify police and CRN so that CRN can dispatch a co-responding mobile team.^[]Ibid. There is limited data thus far to draw conclusions about the pilot’s impact, but PPD CIT Training Coordinator Sabrina Taylor said officers are reporting MCT response times that “feel faster,” and the police incur no additional cost from the effort because it complements CRN’s ongoing work.^[]Galdys and Taylor, March 4, 2020, call; and Moody, June 18, 2020, call.

However, these partners have also come to agree that forgoing police involvement when appropriate and sending more 911 calls to CRN is an important priority with the potential to improve outcomes for people in crisis. To get “upstream” from police contact, as Crisis Response Network’s Manager of Contact Center Operations Matthew Moody put it, CRN developed a plan for 911 dispatchers to relay calls to a CRN specialist instead of first dispatching an officer for the many calls that do not require police intervention and may not require any kind of on-scene response.^[]Moody, June 18, 2020, call. CRN specialists, clinicians with a bachelor’s or master’s degree and four to eight years of experience, conduct in-depth risk assessments to screen these calls. Based on these assessments, the specialists can resolve situations through phone support and referrals or send an MCT to the scene.^[]Ibid. Yet there is still work to be done to overcome existing policies and practices that default to sending police rather than directing calls to CRN.

“When you call 911, 911 deals with it,” he explained. “If you start with 911, you’re starting with a justice lens.”^[]Galdys and Taylor, March 4, 2020, call. Many people have been taught to call 911 to handle all emergencies, and like many communities, Phoenix will send police when police are asked for. Terry McDermott, a Phoenix advocate with mental illness who presents at CIT trainings with PPD officers, praised the work of CRN’s crisis line specialists and MCTs but believes most people are unaware of these resources and are more likely to turn to 911 during a crisis.^[]Terry McDermott, advocate, Phoenix, Arizona, July 16, 2020, telephone call.

PPD and CRN have taken action to begin changing this culture. “We knew we needed our [911] operators to trust the crisis operators,” Dispatch Supervisor Myla Marovich explained, “in order to be able to hand the calls over and trust they’ll do the right thing for that caller.”^[]Myla Marovich, shift supervisor, Phoenix Police Department, and Sabrina Taylor, CIT training coordinator, Phoenix Police Department, June 4, 2020, telephone call. After conducting a survey of Phoenix’s 911 operators, PPD determined that persistent dispatcher concerns around liability made them less likely to send a call to CRN. These dispatchers feared that threats to safety could emerge and they might be reprimanded for not sending patrol.^[]Galdys and Taylor, March 4, 2020, call; and Moody, June 18, 2020, call. Indeed, CRN specialists concerned about risk assessment findings gathered over the phone can send calls back to 911 within a few minutes to dispatch police as necessary.^[]Moody, June 18, 2020, call. A growing number of people in the department recognize that, if they want to encourage more diversion, they need to develop a policy that explicitly directs dispatchers to divert calls to CRN in certain circumstances, rather than just presenting it as an option.^[]Marovich and Taylor, June 4, 2020, call.

Collaboration and cross-center learning

Training between PPD and CRN has been a key strategy in encouraging the diversion of more 911 calls. Through February and March 2019, the police department coordinated with CRN to roll out a new dispatcher training for this purpose. The training consisted of 30-minute videos on mental health and PPD’s broader CIT efforts, as well as a two-hour in-person meeting with a CRN manager to discuss the evolution of Arizona’s crisis system.^[]Galdys and Taylor, May 7, 2020, call. The manager fielded questions about how the crisis line works and what they can or cannot handle. Moody recounted that “even veteran 911 dispatchers learned there were call types that CRN could take that they didn’t know of before.”^[]Moody, June 18, 2020, call. In early 2020, a CRN manager returned to meet with dispatch supervisors in three training sessions so they could raise any questions that had come up about diverting calls to CRN. Supervisors were also briefed on a pilot that would have placed the CRN manager in the PPD communications center for 20 hours per week. After the CRN manager participated in two days of observation and answering dispatchers’ questions, the COVID-19 pandemic put the pilot on hold, but CRN and PPD nonetheless observed a temporary increase in the number of calls diverted to CRN shortly after the training sessions. The following graph captures mental health–related 911 calls in Phoenix that did not receive a police response and demonstrates an increase in referrals.^[]Taylor, September 2, 2020, email.

The brief uptick underscores the value of ongoing education and engagement between the communications centers, as well as what might be gained from a formal departmental policy requiring greater call diversion.

Phoenix partners understand that rethinking how emergency communications responds to crisis calls will play an integral role in driving change. Consequently, PPD’s Communications Bureau increasingly serves as a key stakeholder in Phoenix’s crisis response efforts. PPD and CRN now routinely exchange feedback as they review calls together to determine how they might be handled differently.^[]Moody, June 18, 2020, call. Phoenix’s crisis response program engages a wide variety of partners and includes law enforcement–friendly crisis services and trainings tailored for diverse stakeholders, among other program elements. Although the Communications Bureau’s efforts to rethink Phoenix’s crisis system and push responses upstream from police are still relatively new—“We have a lot of catching up to do,” as dispatch supervisor Marovich put it—they point toward crisis response programs that broaden their focus to include not only improved police responses but also improved community-based responses and reduced police contact.^[]Marovich and Taylor, June 4, 2020, call.