Title
Recommendation to Receive a Twelve-Month Update on the Community Assessment Response and Engagement (CARE) Team Pilot Program and Transition the Program from a Pilot to an Ongoing Program. (Fire 10032270)
Body
To: Honorable Mayor and Members of the City Council
From: Jennifer Ott, City Manager
EXECUTIVE SUMMARY
The Alameda Fire Department (AFD) Community Assessment Response and Engagement (CARE) Team began delivering services on December 16, 2021 and is funded through June 30, 2023. The CARE Team consists of trained AFD personnel staffing a program-dedicated vehicle on a 24/7/365 basis to provide services within the City of Alameda (City) related to mental health emergencies. The CARE Team staff consists of a licensed Paramedic and Emergency Medical Technician (EMT) trained in de-escalation and behavioral health. The CARE Team triages and assesses clients to assist them with navigating the best path forward in obtaining needed services. Additionally, through the contract with the City, Alameda Family Services (AFS) provides real-time case consultation for the field units, clinical field response when needed, and case management/follow-up support for Care Team clients.
The CARE Team has proven its effectiveness during the 12-month pilot and responded to a total of 1,146 requests for service. In collaboration with AFS, the program assisted many clients with navigating their situations and providing a positive path forward.
This report provides data collected (detailed in Exhibit 1) as part of a comprehensive 12-month evaluation (December 2021 to December 2022) of the CARE Team program delivery model.
Staff recommends that the CARE Team be transitioned from a pilot to an ongoing program serving the Alameda community with comprehensive crisis mental health services. This would require allocating General Fund funding during the Fiscal Year (FY) 23-25 budget process as well as seeking additional local, state, or federal funding or financial reimbursement sources. Also anticipated in the FY 23-25 budget request is a Management Analyst position to support ongoing program oversight needs that other AFD staff have absorbed during the pilot. The Management Analyst would support grant research and writing, identify and explore the implementation of other potential program funding opportunities through insurance reimbursement, assume responsibility for program data management and oversight, assist with training coordination/tracking, provide liaison duties with program collaborators, manage program expenses, assist with quality assurance oversight, prepare reports, provide community outreach and education about the CARE Team and perform other program management duties as identified in support of the Emergency Medical Services Captain.
BACKGROUND
In response to events locally and throughout the nation, along with a demand for restructuring of law enforcement agencies, the City, through the formation of a Community-led Steering Committee on Police Reform and Racial Equity, re-evaluated the methods of response to mental health emergencies in 2020-2021.
On March 16, 2021, the City Council considered recommendations from the Community-led Steering Committee on Police Reform and Racial Equity. On May 8, 2021, the City Council convened to consider a referral on related matters and provided eight additional action items for follow-up; one item included options related to mental health crisis response.
City Council gave the City Manager direction on July 6, 2021, to proceed with a mental health crisis response pilot program that would be AFD based, working closely with a vendor that would provide case management and licensed clinician services. And on September 21, 2021, City Council authorized an agreement with AFS to provide the required case management and licensed clinician support to implement the AFD managed mental crisis response model.
Current practices for behavioral health emergencies, public health concerns, and the homelessness crisis are outdated and place incredible demand on public services. Law enforcement officers have been tasked with handling mental health calls; however, training for officers in addressing mental health emergencies has been inadequate throughout the country. The result is that clients historically are not provided the most affective services, such as appropriate evaluations, crisis stabilization plans, treatment opportunities, and case management post-mental health crisis. Before the CARE Team, behavioral health clients in Alameda were transported to local emergency rooms or the County Mental Health Hospital (John George) for services. These services often provide little assistance in addressing the client's short-term and long-term needs.
The CARE Team Pilot Program was developed to shift responsibility for managing mental health crises from the Police Department (APD) to the CARE Team, building upon infrastructure from AFD’s Emergency Medical Services Division.
The CARE Team is supported by Alameda County Behavioral Health Care Services and the Alameda County Emergency Medical Services Agency (LEMSA). LEMSA has provided AFD with a special provision to operate the current pilot program and closely monitors the outcomes to see if the CARE Team concept could be expanded to other fire departments throughout Alameda County and the state. Since the CARE Team’s inception, the Hayward Fire Department has launched a similar program, and Alameda County Fire Department is exploring options to provide similar services to some of their response areas, based on the successes of the City’s CARE Team.
The CARE Team Operations Key Stakeholder Advisory Committee reviews outcomes, program progress concerning dispatch, on-scene interaction, client assessment, disposition, documentation, consultation, destination interactions, and the CARE Team/AFS referral process. The Quality Management Team meets to discuss specific calls for service and program needs with oversite from the Fire Departments Medical Director.
DISCUSSION
The City Manager’s Office, AFS, AFD, Alameda County Emergency Medical Services Agency, APD, and Alameda County Behavioral Health Services have continuously evaluated the CARE Team Pilot Program since implementation and made modifications to meet the program objectives. The pilot program objectives since its inception in December 2021 include:
• Provide an alternative to APD involvement in calls for service for community members experiencing a mental health crisis.
• Allow APD to have officers available to respond to higher-priority calls by assigning the CARE Team to calls associated with people experiencing a mental crisis.
• Foster a robust private-public working relationship between AFD and AFS to foster positive outcomes for community members needing mental health services.
• Assist residents experiencing mental or social challenges with navigating the appropriate resources to allow them a pathway and plan for a safe, balanced life.
• Reduce the repeated need of community members utilizing emergency services to instead progress toward mental health or addiction recovery stabilization.
• Reduce the use of AFD ambulances to transport 5150 patients so they are available instead to respond to higher priority medical calls within the City.
• Reduce impacts on regional emergency departments and psychiatric hospitals such as John George, by identifying alternate treatment facilities and plans for affected community members.
• Provide services to community members who historically haven’t had access to services and assist them in navigating a successful outcome.
During its first twelve months of service, the Team responded to 1,146 requests for service. The responses primarily included mental health responses and calls for other emergencies where the Care Team resources were used to assist with incident stabilization. Of these calls for service, 738 were CARE Team-specific and the Team had client engagement with 621 people. The Care Team averaged 96 calls for service per month for the twelve-month pilot period. AFD saw an increase of 134% in calls for service related to mental health responses compared to the same time frame from the previous year.
The program achieved several highlights and accomplishments during the 12-month period including:
● General Fund and American Rescue Plan Act of 2021 (ARPA) allocation in the FY 22-23 budget to allow the program to continue until June 30, 2023, and complete a comprehensive 12-month evaluation period.
● APD/AFD initiated interdepartmental field personnel meetings to discuss coordination of response for field units. The meetings assisted with streamlining the response and coordination between APD/AFD at the scene.
● Alameda Health Care District (AHCD) approved $250,000 for FY 22-23 to support the program and support the goal of reducing the impact on the Alameda Hospital Emergency Department and other medical receiving facilities throughout Alameda County.
● Worked with Assembly Member Mia Bonta’s Office to identify funding opportunities for the CARE Team and in the State Budget FY 22-23 $1.8 million was appropriated for the CARE Team.
● Funding was allocated in the AFD FY 22-23 budget for a new vehicle for the CARE Team to allow for more equipment space and personnel. Fleet services have ordered the vehicle and delivery is pending.
● Two AFD members attended a train-the-trainer for the Pro-ACT de-escalation course in September 2022. AFD initiated training for all members in this de-escalation training. Pro-ACT is based on a set of principles that focus on maintaining client dignity and keeping people safe, offering First Responders the skills needed to reduce or avoid restraint.
● 26 Firefighter/Paramedics and Emergency Medical Technicians completed training in mobile crisis response and 5150/5585 protocols. As new Paramedics complete their probation, they will complete the CARE Team curriculum. This process provides adequate CARE Team staffing levels to ensure uninterrupted response and service.
● Initiated Vicarious Trauma/Peer Support training for CARE Team members with the support of AFS. The Fire Department continues to explore opportunities to expand this support/training to include all members of the AFD.
● New Beyond Lucid Technologies data software implemented to allow for the use of MediView as the primary data tracking tool for the CARE Team. There are some data reconciliation challenges between AFD and AFS and a Management Analyst would support this process.
During the program's first twelve months, the AFD and AFS partnership allowed on-scene support, follow-up navigation, and wrap-around services and there were 499 total referrals to AFS. Of these, 355 were unduplicated client referrals. During the first twelve months of the Alameda CARE Team, AFS was utilized 192 times for on-call clinician services to support the AFD members operating in the field. AFS, to date, has served a diverse group of clients through their case management contracted services. Exhibit 1 details client demographics as well as the pilot program calls for service, time on task, transport destinations, initial client referrals and outcomes, and Narcan use.
During the pilot, AFD worked with APD to coordinate data comparison and analysis of the impact of the CARE Team on APD operations. In the first twelve months, APD Computer Aided Dispatch (CAD) showed that APD had been dispatched to 594 calls for service that included dispatching the CARE Team for response. The CARE Team did not respond with APD to 23 calls due to being committed to another call and unavailable. An analysis of the APD 5150 calls for service before and during pilot program shows that with the CARE Team’s ability to become the primary responder on these calls, it significantly reduced APD’s time and reporting on these calls, despite the volume of 5150 calls increasing 20% during that time.
Overall, the pilot program data shows that the CARE Team positively addressed the objectives established for the program. The CARE Team continues to monitor data and objectives to ensure the program continues to meet its objectives. Some items identified for further evaluation and research include:
• Continue to evaluate dispatch procedures and adjust as required to maximize the CARE Team and AFS utilization.
• Identify potential state and federal funds to support the program long-term.
• Collaborate with Alameda Alliance for Health on possible Medi-Cal reimbursement mechanisms that would have no financial impact on the client.
• Explore additional options to meet the First Responder’s mental health needs. This is a high priority and AFD hopes to develop a department Peer Support Program in the near future.
• Work with Alameda County Behavioral Health to identify ways to avoid duplication services provided by their Mental Crisis Response Teams while ensuring clients receive appropriate case management follow-up with client information available to both agencies so client services are tracked.
• Continue to train all AFD personnel to staff the CARE Team as needed and provide a knowledge base that can be used when assigned to other apparatus (ambulances, fire engines, etc.).
• Continue to work closely with APD to identify ways to reduce the need for APD response to specific mental health calls so they can be available to respond to other priority calls for service.
• Closely monitor the implementation of the CA Care Court Program to see how it may be used to support some clients without deterring others from using the CARE Team. It is expected that the Care Court program will be introduced in Alameda County in 2024.
Narcan Data in Response to January 17th Council Direction
During its January 17, 2023 meeting, City Council requested information on Naloxone (Narcan) be included in this report. Narcan is a medicine that rapidly reverses an opioid overdose. Narcan can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose. But Narcan has no effect on someone who does not have opioids in their system, and it is not a treatment for opioid use disorder. Examples of opioids include heroin, fentanyl, oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, and morphine. During the CARE Team pilot program, the CARE Team did not encounter an opiate overdose that required the use of Narcan. AFD emergency responders did utilize Narcan to either rule out an opiate overdose or treat a patient that was experiencing an opiate overdose, as described below in more detail. Both AFD and APD carry Narcan.
In the 2022 calendar year, AFD administered Narcan 44 times. Of the 44 administrations, 14 were documented as a suspected opiate overdose. The other 30 administrations were used in accordance with Alameda County EMS protocols to ensure opiates were not the cause of the patient’s presentation. Two of the 14 instances were for a patient in cardiac arrest. In 2022 APD utilized Narcan four times on calls where they encountered an unresponsive person that they suspected may have used opiates. In total, between AFD and APD, Narcan was administered 48 times in 2022, and 14 instances were documented that the patient had evidence of opiate utilization.
Alameda Fire & Police Department Narcan Utilization for 2022
ALTERNATIVES
• Transition the CARE Team pilot program to a permanent program within the Fire Department.
• End the AFD CARE Team services effective June 30, 2023.
• Direct the City Manager to explore other models for providing comprehensive Mental Health Services to the Alameda Community
FINANCIAL IMPACT
The CARE Team is fully funded for the pilot period through the end of FY 2022/23. If City Council directs staff to continue the program beyond June 30, 2023, the annual cost of personnel, services, and supplies is estimated to total approximately $2.4 million in FY 2023/24, subject to future City Council appropriations approval as part of the FY 2023-25 Biennial Budget process. As noted above, the CARE Team was allocated $1.8 million in the State’s FY 2022/23 budget, which could be used to offset the General Fund contribution for the program in FY 2023/24. Continuation of the program potentially obligates the General Fund to approximately $2.4 million in ongoing costs, although staff would continue to pursue alternative funding sources.
MUNICIPAL CODE/POLICY DOCUMENT CROSS REFERENCE
This action is consistent with the Alameda Municipal Code.
ENVIRONMENTAL REVIEW
This action is exempt from review under the California Environmental Quality Act (CEQA) section 15378(b)(5) (not a project); and section 15601(b)(3) (no significant environmental impact).
CLIMATE IMPACT
This action is consistent with the City's Safe Climate Resolution No. 15510.
RECOMMENDATION
Staff recommends that the Alameda CARE Team be transitioned from a pilot program to a permanent program within AFD, allowing for AFD to continue to serve the Alameda community with comprehensive 24/7/365 crisis mental health services. This recommendation is based on the data obtained during the pilot and the objectives being met proving that the CARE Team is a successful alternative to law enforcement being the primary responder on mental health crisis calls. The program has also proven that incorporating an outside contractor for clinical and case management support has successfully supported the short-term needs of those needing intervention and focused case management.
Respectfully submitted,
Nicholas Luby, Fire Chief
Financial Impact section reviewed,
Margaret O’Brien, Finance Director
Exhibit:
1. CARE Team Data