From crisis to care: Michigan's evolving behavioral health ecosystem

January 31. 2023

Download slides     Q&A

When someone experiences a mental health emergency, our response can provide a pathway to treatment or exacerbate their challenges. Michigan has made progress in helping people in crisis access integrated, high-quality careand we have much further to go.  During this webinar, key leaders on the forefront of this work talked about how state and local agencies, providers, and communities are partnering on whole system responses, ensuring those in need have someone to call, someone to respond, and a place to go.

Event speakers include:

  • Lynda Zeller, Senior Fellow, Behavioral Health - Michigan Health Endowment Fund
  • Steven MaysDiversion Administrator, Mental Health Diversion Council Liaison - Michigan Department of Health and Human Services
  • Krista Hausermann, Section Manager, Crisis and Stabilization Services - Bureau of Specialty Behavioral Health Services Michigan Department of Health and Human Services
  • Sheryl Kubiak, Dean, Wayne State University School of Social Work, Director, Center for Behavioral Health and Justice
  • Leonard Swanson, Crisis Response Manager, Center for Behavioral Health and Justice


Watch the panel discussion     Download

Following the presentations, the panel of experts had a robust discussion in response to audience questions. Below you will find reponses to all the questions received during the event, organized by topic. 

  • Someone to call

    What happens with an individual's data when they call 988? Community members are afraid of data tracking or police being sent to their location without their knowledge or consent.

    988 caller data is protected by HIPAA.   People can call 988 anonymously and most callers do. 988 Crisis Specialists receive specialized training to work collaboratively with callers to avoid law enforcement being sent involuntarily whenever possible.  A retrospective review is conducted by the 988 Center's administration anytime 911 is called. Nationally less than 2% of 988 calls require 911 involvement. In Michigan it is even less. In December there were 6,466,988 calls in Michigan. Of these calls only 15 had involuntary intervention by first responders and 7 had voluntary intervention. (Krista Hauserman)

    Doesn't that confuse things when you have a separate 988 line and a CMH line operating instead of one number to respond quickly?

    988 is for people in Michigan who don't know where to go for help. There is no requirement to call 988 to access crisis care. CMHSP crisis lines are an important part of the specialty behavioral health system for Michiganders with some of the most severe behavioral health needs. This integrated care is important for their treatment and support. Almost half of the CMHSPs provide a type of warmline support at least part of the time similar to 988 but the rest don't. Michiganders can receive crisis care regardless of which line they call. We work to educate Michiganders through outreach efforts.  (Krista Hauserman)

    It appears as though there is a potential disconnect between the ideals of CIT and 9-1-1 national "best practice" standards followed by many 9-1-1 centers.  How is this being addressed? 

    Yes, we see a disconnect between 9-1-1 centers and CIT programs. When the CBHJ polled 98 dispatchers, only 14% said they send out CIT officers, and even fewer had enough CIT officers to send. We encourage more CIT training for police officers across the state, and we encourage existing CIT programs to coordinate with their 9-1-1 dispatch centers (Leonard Swanson).

  • Someone to respond

    What role does law enforcement play in Mchigan's 988 response? When 988 was first released nationally, I heard some activists raise alarms that police may arrive and that this could perhaps lead to the escalation of crisis or violence?

    Michigan 988 centers and 911 have developed a process flow to help callers who are in imminent risk. Law enforcement is rarely called and only when absolutely necessary. A retrospective review is conducted by the 988 Center's administration anytime 911 is called. Nationally less than 2% of 988 calls require 911 involvement. In Michigan it is even less. For example in December there were 6,466 988 calls in Michigan. Of these calls only 15 had involuntary intervention by first responders and 7 had voluntary intervention. (Krista Hausermann)

    If law enforcement is called out to a person who is in a suicidal crisis with a weapon, is there a requirement for them to try and connect the person immediately for intervention? If not, is there a program available (that has funding) to create some sort of team consisting of mental health professionals? 

    Law enforcement are the primary responders to any emergency involving a weapon anywhere in the country, even in cities with progressive models such as CAHOOTS (Eugene, OR) or STAR (Denver, CO). Certain jurisdictions operate co-response teams where mental health professionals attend suicide calls where weapons are involved. Mental health professionals are also often part of hostage negotiation teams where persons may be threatening themselves or others. Ideally, once the situation has been de-escalated, and no crime has been committed, the first responders would connect the person to appropriate mental health services. CBHJ data suggests mobile crisis and co-response teams are more effective than law enforcement in linkage to post-crisis services. (Leonard Swanson)

    It's important to highlight that mobile crisis teams have the ability to not only de-escalate and establish follow-up services for the individual in crisis, but perhaps just as important, to consult with the family and natural supports who are on-scene to get background and factual info. A person in crisis (and often, even out of crisis) is usually not able to provide accurate information about their history or current mental health and living situation.

    Agree! Connecting with family members, friends, and others on the scene are an important aspect of the mobile crisis role. (Leonard Swanson)

    Is there any data on the collaboration between law enforcement and clinicians with the co-response? 

    If you mean data on the outcomes of the program, we included a few short-term disposition outcomes in the slides, and we are working on analyzing long-term outcomes of the clients. If you mean data that assesses the strength of the collaboration between law enforcement and clinicians, a few studies have documented increased collaboration and model acceptance between clinicians and law enforcement through creating a co-response model (Shapiro, 2014; Puntis, 2018; Scott, 2000). (Leonard Swanson)

  • A place to go

    How are crisis residential programs, a staple in the crisis continuum, being promoted and contextualized in the state's system improvement efforts? Are any efforts being made to improve the presence and quality of crisis residential units? 

    Agreed Travis. Crisis Residentials are an important part of the crisis continuum. CSUs will be required to coordinate with Crisis Residentials. They will also eventually be included as an option in the state's psychiatric bed registry. (Krista Hausermann)

    Is it faster to take a person to the ED or is there an awareness issue with law enforcement?

    We often hear law enforcement complaints of long wait times in emergency departments. Unfortunately, jails bookings can be more expedient than EDs, which can incentivize law enforcement to arrest in lieu of treatment. Crisis stabilization units and similar facilities should establish procedures to handle intakes that are faster than both EDs and jails. (Leonard Swanson)

    I hope that the final rules for CSUs will allow them to be operated by CMHs and other nonprofit agencies. If we really want to see them established in meaningful numbers, we cannot rely on CMHs alone to get the job done. In our PIHP region, multiple agencies provide SUD services, but our CMH is the gatekeeper of all Medicaid mental health funds. This type of monopoly does not lend itself to innovative and quick response initiatives. 

    Non-profit agencies will be able to provide CSU services if they hold a contract with a CMHSP as a preadmission screening unit and a CSU. The Certification Rules must follow the law. The law limits CSU providers to be psychiatric hospitals, hospitals or preadmission screening units. To stay in alignment with the law, promote one infrastructure with diverse funding, and continuity of care, all CSUs must be a CMHSP preadmission screening unit or have a contract with a CMHSP as a preadmission screening unit. Per the Mental Health Code and other state rules, PIHPs manage Medicaid crisis services and CMHSPs must provide crisis services to people with Medicaid (Krista Hauserman)

  • AOT and mental health

    How can you help families recognize SMI? What symptoms to identify? How to let confused families know what's happening to their loved one?

    The National Association on Mental Illness (NAMI) and NAMI-Michigan have great resources to help families and loved ones understand mental illness. Additionally, check out the assisted outpatient treatment toolkit for more resources specific to AOT. (CBHJ)

    It would be useful for your map to include the first step as family/friends trying to petition probate to start the chain.

    There are many possible routes to crisis services, and it's true that petitions to probate court is a route, though there are far fewer probate court petitions than 911 calls for service or calls to the CMH office. We have elected to simplify this map to only include the most common routes to care (Leonard Swanson).

    What is the recourse if individuals on AOT only don't comply, but don't need inpatient psychiatric care?

    Check out the assisted outpatient treatment toolkit for more resources specific to AOT. Your question has been submitted for review to our AOT content experts. (CBHJ)

    AOT only (no inpatient days) originating from MDOC prior to release- if non compliant, but does not appear to be a person requiring treatment at present, can the CMH psychiatrist evaluate and complete a cert to that effect, and dismiss the AOT?

    Check out the assisted outpatient treatment toolkit for more resources specific to AOT. Your question has been submitted for review to our AOT content experts. (CBHJ)

    To truly continue addressing upstream issues, please expand analysis to "Assisted Outpatient Treatment"/ kevin's law implementation. In Oakland County, only a psychiatrist (not NP, not psychologist and certainly not parents) can petition for AOT medication compliance. And it only lasts 6 months with almost an impossible likelihood of renewal (again, only by a psychiatrist MD). This is creating a huge hamster wheel of recovery interruption, crisis response, short term treatment, recovery interruption. 

    Check out the assisted outpatient treatment toolkit for more resources specific to AOT. Your question has been submitted for review to our AOT content experts. (CBHJ)

    It doesn't look like there is really a recourse other than having someone picked up and taken to the prescreen unit if they don't adhere to treatment. And doesn't specify if that person doesn't require inpatient what options the CMH has to try to enforce. 

    In cases where a person is non-compliant with treatment, and there is reason to suspect that continued non-compliance would result in harm to the person or others, and the person does not require inpatient treatment, it is possible that assisted outpatient treatment (AOT) could be a solution. Please consult the toolkit available on the CBHJ website for assistance with navigating AOT processes. (Leonard Swanson).

  • Cross-system collaboration

    Please don't forget that jails, hospitals and homeless shelters are the new mental health treatment facilities. 

    Agree! After deinstitutionalization (and the lack of funding to the mental health system), jails, hospitals and homeless shelters encounter more people with mental illness. (Leonard Swanson)

    Is there any data on the collaboration between law enforcement and clinicians with the co-response? Is there mutual respect/equal decision-making power? Do we know the retention rates for clinicians? 
    Yes, a few studies have documented increased collaboration between clinicians and law enforcement through creating a co-response model (Shapiro, 2014; Puntis, 2018; Scott, 2000). Others have documented role confusion and cultural barriers when implementing the co-response model (Bailey, 2018). Respect and decision-making power likely vary by site and personnel. If I were to speculate and make broad generalizations, law enforcement would likely control scene safety, and clinicians would have more say on future safety planning, continuity of care, and appropriate follow-up steps. (Leonard Swanson)

    As a pharmacist in St. Clair County for many years, I observed first hand individuals and families in high-risk/crisis situations. Pharmacists are also medication therapy managers that evaluate and counsel patients utilizing controlled substances and mental health medications. Are pharmacists included in these strategies? 

    I'm not sure about involvement on a local level. This is a great suggestion for a state planning level. (Krista Hausermann)

    Agree that we have not often seen pharmacists included in strategic planning of crisis services. Crisis services are primarily organized on a local county level, and I agree with Krista that it would be tough to find pharmacists consistently across counties. (Leonard Swanson)

    Why are jail meds limited and how do we get that changed?

    Medicaid is suspended upon jail booking, thus complicating the payment structures, and making it more difficult to provide continuity of medication. Allowing Medicaid reimbursement in jails would require a change in federal law, or an expensive state legislative movement. The CBHJ would love to see a movement to continue Medicaid in jails, though it has yet to gain momentum. (Leonard Swanson)

    Are there any support via 2-1-1 or local CIEs?
    I hope this answers your question. 211 is a critical source of resource information for 988. Their data is actually integrated into the MiCAL/988 call platform. 988 staff refer to 211 if the caller has extensive basic support needs. (Krista Hausermann)

  • Representation

    I greatly appreciate the work that each of you and all of you are doing. But given who is most impacted by these needs, particularly those who end up in the criminal justice system, it is really important to have people of color on this panel today. I realize that you may have asked others, but I want to say that this is lacking today and is needed. 

    Thank you for the feedback. The CBHJ is striving to hire both people of color and people who have been impacted by the criminal justice system. We still have work to do in elevating voices of oppressed people in our organization, and we welcome your encouragement. (Leonard Swanson)

    Detroit faces blaring behavioral health disparities (exacerbated by Covid/opioid crisis). Justice-impacted Black males and black-led organizations are rarely funded to lead academic research projects, serve on advisory boards, or entrusted to design a crisis/care continuum. How have the organizations on the panel employed and engaged Black thought leadership and frontline professionals in the design of response models and evaluation? 

    This webinar represents several different organizations, and likely each would have a different response. The data presented here does not suggest a model - but instead reflects what exists. The hope is to use the data - which includes experiences and voices across a wide spectrum of geographic spaces, individuals working within the system, individuals receiving services from the system as well as administrators at the state and county level. Those voices and perspectives are diverse - and welcome additional input and partnerships. (Sheryl Kubiak)

    Why aren't service recipients, families and natural supports included more at the planning table? Especially the MDHHS planning table? Seems like everything they do only gets vetted by CMHs and PIHPs. 

    These are very important voices and we as a system need to do a better job listening to these voices. This is especially critical with crisis services when family members and natural supports can play such a key support role for people in crisis, helping them to feel supported and connected. MDHHS is committed to including the voices of people with lived experience, family members, and natural supports in the development of crisis services in a variety of ways. Listening sessions were held with people with lived experience and their families to help inform Michigan's 988 Planning. People with lived experience were invited and financially supported to be part of the 988 Planning Initiative. MDHHS is now holding listening sessions with people who are from high risk typically underserved groups to ensure 988 services support all Michiganders. People with lived experience have also been members of the Crisis Stabilization Unit Advisory Workgroup which developed the Michigan CSU model. MDHHS is also going to hire three people with lived experience or family members to participate in the CSU Certification Implementation Pilot to ensure the voices of lived experience, family members, and natural supports help guide the implementation pilot. Advocacy organizations will also get an early opportunity to provide feedback on the draft CSU rules. Crisis service models will place a strong emphasis on the inclusion of Certified Peers and Recovery Coaches. (Krista Hausermann)

  • Training, credentials, and education

    What is being done to blend social work education into criminal justice programs? Is anyone looking at how to best embed social workers into police street level response? 

    Yes, there are a few emerging models of police social workers, most notably in Lansing Police Department. Kalamazoo Department of Public Safety, Grand Rapids Police Department, among others, have also hired social workers to join their street level responses. (Leonard Swanson)

    What kind of training or credentials are required by crisis workers answering 988 calls?

    988 Centers must meet national 988/ Vibrant training standards. Each of the call specialists receive extensive training to offer crisis support. MiCAL 988 staff receive over 100 hours of training including ASIST training, then they shadow a senior call specialist, and have supervisor monitoring to verify they have required competencies before answering the phone on their own. There is also ongoing quality improvement monitoring. (Krista Hausermann)

    What counties most need enhanced law enforcement CIT training? 

    The vast majority of law enforcement officers have not received CIT training, or other types of mental health crisis training. It would be simpler to highlight some counties with known CIT programs: Calhoun, Oakland, Berrien, Tri-county (Eaton, Ingham, Clinton), Wayne, Kalamazoo, Jackson, Ottawa, Muskegon, and Marquette. Washtenaw has engaged in both Managing Mental Health Crisis and Behavioral Health Emergency Partnership training modules, which are also supported by the State of Michigan. (Leonard Swanson)

    What type of training is provided to the law enforcement agencies in these counties that provide co-response? 

    The most frequent types of mental health training for law enforcement include Crisis Intervention Team (CIT) and Behavioral Health Emergency Partnership (BHEP) training. Agencies with these training modules are more likely to welcome a co-response model, and I would posit they would be more successful in operating a co-response model. (Leonard Swanson)

    Whatever happened to the 20 hours CIT short course that I heard about at one of the Wayne State webinars?

    You may be referring to the 20-hour Behavioral Health Emergency Partnership (BHEP) training. I would recommend getting in touch with Eric Waddel and Rachel Coy for more information on BHEP and how to bring BHEP to your area. (Leonard Swanson) 

  • Youth and families

    For the data, is there any specification between adult and pediatric systems or utilization? 

    All of the data presented in the webinar focused on adults. We will be analyzing similar youth services over the coming year. Stay tuned! (Leonard Swanson)

    A common theme in the presentations has been barriers in the funding structures. What is MDHHS doing to propose reimbursement changes….also status of KB vs Lyon lawsuit and is a settlement coming. Way to many kids and families with a lot of challenges not getting well deserved services. The settlement is taking way to long. 

    MDHHS recognizes that crisis services must be funded as a public good similar to law enforcement and fire. Services needed to be funded to be available 24/7 not just when the services are actively being provided. MDHHS will work with stakeholders to develop a diverse stable funding model. (Krista Hausermann)

    Within the data, is youth mental health being considered with the same needs? Will this model be for young people as well?

    To respond to the model question both the mobile crisis model and the Crisis Receiving and Stabilization Unit models will be tailored for children, youth, young adults and their families. (Krista Hausermann)

    Behavioral health providers need to acknowledge the huge gap that exists for kids (through age 25) who are covered by the commercial insurance of their low to middle income families. These non-Medicaid families cannot afford to send their kids to private facilities out of state and have very few affordable options, especially for residential care.

    MDHHS is committed to developing a crisis system that supports all Michiganders in crisis regardless of payer type. 988, mobile crisis, and crisis receiving and stabilization units will provide services for everyone. Hopefully a strong crisis continuum will help reduce the need for out of home care. (Krista Hausermann)

  • Funding

    To improve mental health and substance use services in the jail, increase GF funding to the CMH system to serve this population. 

    This is one possibility that could help CMHs provide jail-based mental health services. Another route would be the allowance of Medicaid reimbursement in the jail. (Leonard Swanson)