Chief Danny Smyth
This week’s Tried and True article profiles the Alternative Response to Citizens in Crisis initiative. Police are often involved when people find themselves in crisis associated to mental health. While it may seem counter-intuitive to involve police in a health crisis, the reality is that often these situations are dangerous, and may require police to detain people and take them for medical treatment against their will. The Mental Health Act actually prescribes the role of police in these situations. But is there a better way to help people in crisis? We believe there is.
The ARCC initiative pairs police with mental health clinicians to better respond to people in crisis, and avoid taking them to hospital emergency rooms for evaluation. Inspector Chris Puhach—the WPS lead in this initiative—explains our partnership with Shared Health to better meet a real need in the community.
Chris Puhach, Inspector
Duty Office, Communications Division
ARCC Project Lead
Mental health is a relevant and unpredictable factor in a wide variety of police calls for service. In 2020, members of the Winnipeg Police Service (WPS) made 2,102 trips to a health care facility with persons in crisis and spent approximately 3,533 hours, or the equivalent of 147 days, waiting to turn the person over to clinical staff.
As a result, the City of Winnipeg, WPS, and Shared Health’s Crisis Response Centre initiated a pilot project in December 2021 to offer support to those experiencing mental health crises in Winnipeg. Prior to launch, various community agencies were consulted including individuals and family members with lived experience. The program, Alternative Response to Citizens in Crisis (ARCC), established a co-response model to address 911 calls that require additional support for people experiencing a mental health crisis. ARCC teams are comprised of an officer in plain clothes and a specialized mental health clinician who is a dispatchable resource to assist WPS general patrol (GP) officers when needed.
The ARCC pilot project emerged as a result of the initial work completed through the Bloomberg Harvard City Leadership Initiative which saw representatives from the City of Winnipeg, Winnipeg Police Service, Winnipeg Fire Paramedic Service, Shared Health, and other community agencies work collaboratively to find ways to better align the supports offered with the needs of residents calling 911.
Public demand for civilian crisis workers to respond to non-emergent calls is increasing, however, police need to play a role in these calls for service as these situations can be violent and unpredictable, and usually occur with limited information—but the response can be different. Almost half of the dispatched calls for police service have a medium or high safety risk associated to them, and it is only after officers respond and confirm a situation is safe, that alternative supports can engage and address the psychological and social needs of persons in a mental health crisis.
Dr. James Bolton, Medical Director, Shared Health Crisis Response Services notes, “ARCC will respond in the moment of crisis to provide assessment and intervention in addition to offering follow-up care to those requiring some additional support in the timeframe following a wellbeing call. This may include support in navigating services, connections to available resources or longer-term support for individuals who are frequently in crisis and require a collaborative, system-wide approach”
When speaking of the value a person in crisis receives from ARCC, Erika Hunzinger, Manager, Crisis Response Services says, “this partnership builds upon the continuum of care that is offered through the Crisis Response Centre, Crisis Stabilization Unit, Mobile Crisis Service, Peer Support, Post Crisis Services and our Rapid Access to Addictions Medicine programming. Through ARCC we can support connections to appropriate follow-up services in a manner that is client-focused, offers choice, and is coordinated and collaborative with other services.”
Since its inception, ARCC has made significant progress in providing support to persons who are complex and are frequently in crisis, needing coordinated community support. It is essential that WPS are collaborative partners so that there is an informed, coordinated response whether the individual seeks out health services (e.g. ED, CRC) or a call to 911 is placed. Through ARCC, response plans are developed for these complex individuals that have been vetted by mental health professionals and other supports that may be in that person’s life. Without disclosing non-essential health information, and with consent, it acts as a guide for general patrol officers who are responding when ARCC is not available, providing information such as important professional and natural contacts, what coping tools the individual have available to them, and suggestions on how to help the individual depending on the crisis at the time.
During the first quarter of 2022, ARCC responded to 82 police events. The bulk of calls for service ARCC assisted with were threats of suicide, which accounted for 50% of their deployments. The second-highest call type was Check the Wellbeing, at 21% with the remainder being a variety of other call types. Calls to 911 for suicide threats are increasing. Many individuals experiencing thoughts of suicide that have not caused harm to themselves do not require hospitalization or emergency department visits; though they do require specialized assessment, stabilization/safe planning and connection to services and resources. ARCC brings these skills to the person in their home, preventing the need to transport the individual and wait for assessment and transfer of service to another professional. Not only does this save wait time for GP officers, but also, importantly, improves the experience of the individual and their families who are experiencing the crisis.
The project team has been tracking the mode of ARCC engagements to better understand where ARCC services are needed. There are four modes of engagement by the teams: on-scene assist, referral/follow-up, GP phone consultation, and pre-dispatch consult.
Modes of Engagement
On-scene assistance (ARCC team physically at the scene of the crisis) accounted for 43% of the reactive team’s interaction. This engagement occurs when GP officers request ARCC to attend their location or the team is dispatched simultaneously. Providing this on-scene support allows the clinician to perform a more comprehensive assessment than they could if the person presented to the CRC as the clinician also may gain important information from the individual’s environment or family.
Referral/follow-up occurs when GP has requested ARCC attend and check on someone they encountered on a previous call or ARCC follow-up with someone they interacted with previously. This pre-emptive contact goes a long way in preventing future calls for service and accounted for 21% of engagements.
As ARCC cannot attend every call GP attends, the ARCC team makes themselves available for phone consultations. GP officers are able to phone the ARCC team and explain the situation and have the clinician provide support and direction where possible. The clinician may also be able to speak with the individual while GP is on-scene. This mode of engagement occurred 20% of the time.
Pre-dispatch consults became an early service delivery enhancement due to potential safety risks present that limited ARCC’s response capability. To compensate, ARCC started calling, the person in crisis, as the call waited in the police dispatch queue. This practice allowed the clinician to begin the de-escalation process with the individual and conduct the initial assessment over the phone, much like they would do if the person called Mobile Crisis or attended CRC. This practice allowed ARCC to reach more people and accounted for 16% of engagements.
Evidence-based decision-making is an essential element of the pilot. Data evaluation informs this approach. The following are the Q1 performance measures data.
Performance Measures
1. ARCC operated at 39% capacity in Q1, deploying 44 of 114 possible shifts. The COVID-19 pandemic and pre-existing staffing vacancies impacted capacity. By April the number increased to 48% and continues to trend upward.
2. ARCC assisted 82 events and was unavailable for 75. The unavailable measure reflects an effort to quantify the number of times officers required the services of ARCC but the team was off duty.
3. An 87% remain in community rate was realized this quarter. This measure reflects the percentage of time a person in crisis remains in the community after engagement by the ARCC clinician. Through the support provided by the clinician, the pilot is seeing fewer people being taken to a health care facility because specialized assessment, crisis management and treatment options are brought to them in their own environment. HealthIM (mental health screening tool) data reflects that in the vast majority of calls attended without ARCC, the individual is transported to a facility (471 out of 542 times in Q1 2022), appropriately so, because, without ARCC, general patrol members cannot access health information or specialized assessment and are using the safest option available to them. Anecdotally the pilot has experienced situations where had it not been for the clinician on the scene, officers would have had no option but to apprehend the individual and take them for a psychiatric assessment in the hospital.
4. Twenty-two clients were proactively supported, meaning that collaborative meetings were held or response plans developed, or the individual was connected to a service through ARCC when not actively in crisis.
5. With one quarter behind, the pilot project is 25% complete.
Proactive Efforts
A great deal of attention is placed on the ARCC reactive team and the outcomes of the clinician’s engagement on the scene. While an essential component of the pilot project, the reactive response is far from the bulk of daily work. Many positive outcomes are driven by the pilot’s proactive efforts, and the work done to continually address the needs of those in the community experiencing a chronic crisis. It is through individual engagements that the real success stories and potential of this new service delivery model become visible.
Throughout Q1, 22 people received some form of proactive support from ARCC.
The bulk of proactive efforts have required collaboration with the person’s existing community support network of people and agencies, and ensuring a consistent police response is provided to the individual, when required.
Community Collaboration
Building relationships with those in the community already supporting the person in crisis is an essential component of proactive work. In the most complex cases, this can range from 8 to 10 different government and social agencies working in support of one person. ARCC members participate in systems meetings to identify what the person needs to aid stabilization and reduce dependency on police services.
Consistent Police Response
This collaboration results in a co-created individualized response plan for the person. With a response plan articulated, it is shared with responding officers to ensure consistency in the manner by which officers engage the individual in crisis occurs. This ensures the person in crisis receives what they need to aid stabilization.
These collective efforts create the path to stabilization for a person in a frequent mental health crisis.
Demonstrated Success
One such complex case involves an individual with several unmet needs who experiences cognitive delay and lacks family support due to life circumstances.
In 2021, this individual was involved in 62 different events that required a police response. With behaviour that involved violent tendencies toward support staff and threatening actions that required police intervention, this individual overwhelmed all available support resources. This individual also frequented emergency departments and crisis response services—in Q4 2021 they had 36 visits to a health care facility in crisis. By December, this individual was homeless and moving between shelters.
Their behaviour had conditioned them to perceive the involvement of multiple services was a positive, or a reward, and made them feel better and therefore increased in frequency. Through no fault of the individual, they unconsciously increased behaviour in the hope the reward would be provided.
ARCC began to proactively case manage this individual in January 2022. Through the collaborative and coordinated efforts of nine different government and community agencies, the behaviour of the individual stabilized, resulting in a 24% reduction in calls for police service by the end of Q1. This work was led by ARCC staff. The individual began appropriately using the mobile crisis telephone line for support in managing emotional distress as an alternative option to calling 911. The individual had 14 visits to an emergency department or crisis response centre in Q1 of 2022. A response plan for police was developed to create a consistent, informed, collaborated response for when the individual does call 911. This individual now has consistent housing and an effective support structure to meet specific needs that allow transition away from the justice system and over to the social system. ARCC will continue to monitor the individual’s use of services and check-in from time to time.
Our experience thus far suggests the reactive and proactive ARCC model is effective at responding to the community's need while reducing police calls for service.
The WPS and Shared Health are excited to continue with this pilot and chart the progress of moving crisis response toward community programming and social networks to ensure the right support at the right time.