MARICOPA COUNTY, Ariz.
For more than 20 years, the state has been building an integrated crisis system that has shown success in keeping people with mental illnesses and substance use issues out of jails and hospital emergency departments, and getting them care. The system has been used as an example of best practices by the federal Substance Abuse and Mental Health Services Administration and other organizations like the Vera Institute for Justice. Now, Washington state leaders are looking to the state for inspiration as they rethink local mental health systems.
This month, around four dozen Washingtonians involved in mental health care policy, including state lawmakers, county council members and state agency leaders, visited Maricopa County to learn about the system there.
The visit came as Washington plans the rollout of the 988 crisis line set to go live this summer. State leaders are hoping to use the hotline’s launch as a catalyst to further stitch together pieces of Washington’s heavily siloed and underfunded mental health system. Here’s what they learned about Arizona’s approach, and what it could mean for our state.
No wrong door
The Arizona model starts with a simple but key philosophy: There’s no wrong door into the mental and behavioral health system. Whether a person has a mental illness, addiction problems, an intellectual or developmental disability, or all of the above, everyone gets access to services at the same place.
In Washington, by contrast, patients have a hard time finding help between specialized facilities, the ER, jails and the community. People with criminal or complex backgrounds often get turned away from facilities or struggle to find an available bed, especially if their insurance doesn’t cover the services or they’re uninsured. That means they often go without treatment and end up cycling through the system again.
Dr. Michael Riddle, a medical officer running the RI International Recovery Response Center in Peoria, Arizona, advocates for an integrated approach to behavioral health, thinking through what brought the person into crisis and what will help keep them from crisis again.
“It’s really important to approach every soul that we touch as an investigation,” Riddle said.
“We are detectives. We’re not bouncers” who turn people away if they are too sick or violent, he added.
Arizona’s integrated crisis system, which it has been building for decades, includes mobile crisis teams, a hotline and crisis centers where people can walk in or be dropped off by mobile crisis teams, law enforcement or others. Maricopa County itself has three crisis facilities, dispersed so they’re about a 20-minute drive regardless of where you are.
At the centers, people can get crisis counseling or medication if needed. According to Mercy Care, the Medicaid-contracted provider in Central Arizona, law enforcement dropped off 28,000 people (some may be repeat drop-offs) at crisis centers in 2021; people are rarely turned away.
There’s also no need for people to get medical clearance at a hospital first. Staff are trained to identify medical concerns and reroute people to the hospital if needed, but that occurs only in about 6% of cases. This means fewer people end up staying in hospital emergency rooms waiting for help, reducing the cost of care.
The Arizona system has prioritized making it easy for police to bring people to the crisis center for help: It usually takes less than 10 minutes to drop someone off, so officers can spend more time on other calls, and more importantly, people are kept from needlessly entering jail.
Staff will also connect guests (RI does not refer to them as patients) to housing services or addiction treatment if needed. But the responsibility is on staff to navigate the system for their guests, rather than placing that burden on families and individuals.
The Seattle area has limited crisis care facilities, such as a 46-bed facility run by DESC, and many people in mental health crises end up at local emergency rooms. The Arizona operator, RI, also runs a 16-bed facility in Fife.
In 2020, the Crisis Response Network, which runs a regional hotline and crisis services in Northern and Central Arizona, received more than 258,000 calls. They also dispatched a mobile crisis team 19,440 times, and in a little under half of those instances, a person asked for transportation to a center.
Though Seattle and parts of Washington state also have crisis hotlines and mobile crisis teams, many times those systems are not connected. And when it comes to the few individuals who need further care, there are limited places for them to go.
The treatment center that Washington representatives toured in Arizona was split up into three sections: a crisis center, a short-term bed area and a respite center. The crisis center has 32 beds for people with a high and immediate need. People tend to stay there for 23 hours or less, and regardless of insurance, they get care.
Clinicians assess the client and if someone is an immediate threat to themselves or others, they can be safely restrained, though staff stress that is only used as a last resort. At this stage, people also get medication if necessary. If a clinician finds the person does not need this level of care or they stabilize, people can “step down” into the short-term bed area.
That area consists of 16 subacute beds where people typically spend two to four days. From there they can move into what’s called a “living-room model” respite center. This is a completely voluntary space where people can stay for seven to 10 days.
Arizona experts say it’s a more comforting and therapeutic space, compared to a sterile and loud ER, and it’s certainly cheaper. It’s also a shift away from a binary system that triages patients based on their acuity or severity of symptoms, meaning people don’t have to wait until they’re “sick enough” to seek care — and their treatment doesn’t start in an emergency room.
The crisis system here is also partially staffed by peers who have firsthand experience with mental illness or substance use disorder — 60% of the staff at this center identify as such. Notably, the rate of people flipping from involuntary to voluntary care is also quite high at 70%. Washington, in comparison, does not make ready use of peers. During the last legislative session, a bill to expand the peer workforce was floated but ultimately didn’t make it.
Another difference is that repeat admissions at the crisis center are seen as a success.
“That’s not a failure. That’s community service,” said Jamie Sellar, chief strategy officer at RI International. “That’s going to keep them out of a hospital for 11 days. It’s going to keep them out of jail on misdemeanor charges.”
Arizona also has another key difference that officials say helps streamline their ability to move people through care: Arizona’s involuntary treatment law (the point at which someone’s civil liberties are taken away due to a severe mental health crisis) states that staff cannot be held liable if, upon release, a patient causes harm to another person, as long as staff take “reasonable precautions” to prevent harm.
In Washington, however, the laws around liability are fuzzier. “Given the case law and the potential for large financial judgments, the culture in Washington state around behavioral health provider liability is quite cautious,” the Washington State Hospital Association told The Seattle Times. This means, for example, staff here may be more likely to call in designated crisis responders who can involuntarily commit someone, rather than face potential litigation — contributing to bottlenecks in the system and frustrating patients and families.
To fund its system, Arizona uses what’s called a braided funding model. Federal, state and county dollars are coupled with federal grants. That money is then disseminated to the regional behavioral health authority, which contracts with providers to deliver services to people. Arizona spends more per capita ($216.87) and per client ($9,210) than Washington, which spends $128.46 per capita and $5,938 per client, according to 2015 data analyzed by the American Addiction Centers — though advocates say spending the money on mental health care means much less needs to be spent at jails and hospitals.
Arizona also maximizes parity — the requirement that insurers pay for mental health care equally with physical health care — by billing commercial insurance for as many crisis services as possible.
In Washington’s funding model, behavioral health facilities must individually charge Medicaid and commercial insurers, on top of securing additional money through grants, which makes long-term sustainability hard.
Much of Arizona’s mental health system is a response to Arnold v. Sarn, a class-action lawsuit filed after the state was found to not be serving people with severe mental illness despite previously passing a law that said it would provide integrated treatment services. The case was finally settled in 2014, and now years of work have gone into reconfiguring the behavioral health and crisis system.
“I came to Arizona in 2004 to a crisis system that was existing but not working well,” said Dr. Chris Carson, an emergency room psychiatrist now working at Connections Health Solutions, an organization providing crisis services in Phoenix and Tucson.
“We look back over our shoulder from 2022 — and that process is not complete by any shade of imagination — but we’ve made a great deal of progress across the board.”
Carson points out that though the state has worked to fine-tune the crisis model, it struggles with systemic challenges linked to mental health like homelessness and substance use. Like much of the U.S., Arizona also faces a staffing shortage with a workforce that is burned out and underpaid. The Phoenix metro region is also struggling with a growing housing crisis, as rents rise and push people out of housing. Still, Carson says, the model here should be refined and replicated everywhere.
Rep. Lauren Davis, who was on the Arizona trip along with Rep. Tina Orwall, Sen. Manka Dhingra, Metropolitan King County Councilmembers Girmay Zahilay and Sarah Perry, community advocates, and others from state agencies, has already committed to taking those lessons and applying them to a new crisis center in Lynnwood. Originally the project was going to build a new jail with more beds. Davis and other local leaders pushed to instead reduce the number of jail beds and dedicate at least 16 short-term crisis beds for people with mental health problems.
“[Arizona] gave us the playbook. Right? The playbook is those three things,” said Davis, referencing the crisis phone lines, mobile teams and crisis centers.
Davis said most of the work now is connecting the dots across those three systems, and increasing funding for behavioral health.
“We’ve actually made substantial investments in all three. Now we need to actually do it.”