Title
Recommendation to Receive a Six-Month Update on the Alameda Community Assessment Response and Engagement (CARE) Team Pilot Program. (Fire 10032270)
Body
To: Honorable Mayor and Members of the City Council
EXECUTIVE SUMMARY
In response to events locally and throughout the nation, along with a demand for restructuring of law enforcement agencies, the City of Alameda (City), through the formation of a Community-led Steering Committee on Police Reform and Racial Equity, reevaluated 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 Fire Department based, working closely with a vendor that would provide case management and licensed clinician services.
On September 21, 2021, City Council authorized the City Manager to negotiate and execute an agreement with Alameda Family Services to provide the required case management and licensed clinician support to implement the Alameda Fire Department-managed mental crisis response model. A contract for services was executed on December 8, 2021.
The Alameda Fire Department's Community Assessment Response and Engagement (CARE) Team started delivering services on December 16, 2021. The CARE Team consists of trained Alameda Fire Department (AFD) personnel staffing a program dedicated vehicle on a 24/7/365 basis that provides services within the 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 case consultation for the field units, clinical field response when needed, and case management/follow-up support for Care Team clients.
Since its inception, the CARE Team has proven to be successful. The Care Team has responded to a total of 529 requests for service in its first six months of operation. Of those 529 responses, the CARE Team responded to 471 mental health responses and had 290 documented client engagements. In collaboration with AFS, the program has assisted multiple clients in navigating their situations and providing a positive path forward.
This report intends to update the City Council on the data collected in the first six months of the Alameda CARE Team pilot program. It is being provided as requested, with the pilot program being funded through June 30, 2023. As part of receiving Fiscal Year 2022-23 funding, AFD is committed to providing ongoing status updates, including six and twelve month updates. The current program funding allows for a comprehensive evaluation of the program delivery model.
BACKGROUND
Current practices for behavioral health emergencies, public health concerns, and the homelessness crisis are outdated and place incredible demand on public services. Additionally, recent events have prompted a community call to restructure public safety, law enforcement, and governmental policies.
Law enforcement officers have been tasked with handling mental health calls; however, training for officers in dealing with mental health emergencies has been inadequate. Law enforcement officers and private ambulance personnel who transport clients are not trained in behavioral health assessments. The result is that clients are not provided the most appropriate services, such as crisis stabilization plans or treatment opportunities.
Before the CARE Team, behavioral health clients in Alameda were transported to local emergency rooms or the County Mental Health Hospital for services. These services are often not the most appropriate and provide little assistance in addressing the client's short-term and long-term needs. Additionally, these facilities have been severely impacted by having clients unnecessarily transported to these facilities, thus putting an unneeded strain on local hospitals and mental health services. Transporting behavioral health clients via 911 ambulances in instances where medical attention is not necessary is costly and further strains the capabilities of the City of Alameda 911 system.
The Alameda Fire Department was in a unique position to address the needs of Alameda by building upon our existing infrastructure available through our department's Emergency Medical Services Division and therefore developed the Alameda CARE Team Pilot Program.
The CARE Team Pilot Program was developed to shift specific responsibility for managing mental health crises from the Police Department to non-police agencies as a recommendation of the community-led committees on police reform and racial equity.
The Alameda CARE Team is supported by Alameda County Behavioral Health Care Services and the Alameda County Emergency Medical Services Agency (LEMSA). The LEMSA has provided AFD with a special provision to operate the current pilot program and closely monitors our outcomes to see if the AFD CARE Team concept could be expanded to other fire departments throughout Alameda County and the state.
The CARE Team Operations Stakeholder Advisory Committee provides oversight to review outcomes, program progress concerning dispatch, on-scene interaction, client assessment, disposition, documentation, consultation, destination interactions, and the CARE Team/AFS referral process. The Advisory Committee does not create policy but assists with providing direction as the program continues to develop.
DISCUSSION
The City Manager’s Office, AFS, AFD, Alameda County Emergency Medical Services Agency, Alameda Police Department (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 program objectives have remained consistent since starting the pilot in December of 2021:
• Provide an alternative from 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 residents or visitors 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 to have a pathway and plan for a safe and balanced lifestyle.
• Reduce the repeated need of community members to utilize emergency services to progress towards mental health or addiction recovery/stabilization.
• Reduce the use of AFD ambulances to transport 5150 patients so that they are available to respond to higher priority medical calls within the city that have continued to increase with population growth.
• Reduce census impacts on regional emergency departments and psychiatric hospitals (John George) by identifying alternate treatment facilities and plans for affected community members.
• Provide services to community members that have historically not had access to services that could assist them in navigating a successful outcome.
Since December 16, 2021, the CARE Team has been in service 24/7. During its first six months of service, the Team responded to 529 requests for service. The responses included primarily mental health responses, in addition to calls for other emergencies where the Care Team resources were used to assist with incident stabilization. Of the 529 total calls for services, 471 were CARE Team specific in nature. Of the 471 mental health responses, 290 had client engagement with the Team. The Care Team averaged 88 calls for service per month for the first six months. AFD saw an increase of 74% 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 first six months of serving the community. These items included the following:
● Funding is allocated in the FY 2022-23 budget to allow the program to continue until June 30, 2023.
● APD/AFD initiated interdepartmental field personnel meetings to discuss coordination of response for field units. The meetings assisted with streamlining the response to calls and coordination between APD/AFD on the scene to meet the program objectives.
● Alameda Health Care District (AHCD) approved $250,000 for FY 2022-23 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 in the California State Budget FY 2022-23.
● All AFD CARE Team positions were filled during the annual bid process by members volunteering to serve in the CARE Team capacity.
● Funding was allocated in the Fire Department budget FY 2022-23 for a new vehicle for the CARE Team that will allow for more equipment space and personnel.
● Two AFD members volunteered to attend a train-the-trainer for de-escalation course in September. Upon completion, these members, along with AFS, hope to provide this training department-wide.
● Total of 26 Firefighter/Paramedics and Emergency Medical Technicians have completed training in mobile crisis response and 5150/5585 protocols.
● Initiated Vicarious Trauma/Peer Support training for CARE Team members with the support of AFS. Exploring possibilities to expand this training to include all members of the AFD.
● With the implementation of the 9-8-8 three-digit calling capability for the Suicide Prevention Hotline, AFD participated in coordination discussions with key stakeholders leading up to the July 16 go-live date.
● New data software contract executed with Beyond Lucid technologies to allow for the use of MediView as the primary data tracking tool for the CARE Team. AFD had hoped to have the new system functional by July 1. Due to interface challenges with the Computer Aided Dispatch system, this date was not met. The hope is that the system will be online by September 2022.
● Ongoing engagement of the CARE Team Operations Advisory Committee took place in July 2022, and the Quality Management Team continues to meet and discuss specific calls for service and program needs.
The following data has been collected between Alameda Fire Department and Alameda Family Services during the first six months of the pilot program:
CARE TEAM Demand for Services December 16, 2021, to June 16, 2022 
Calls for service during the first six months were concentrated between 8 AM and 8 PM daily. The time on task (time the Care Team unit is committed to a call for service) for field responders has fluctuated during the first six months of the pilot program. The longest on-scene time for the CARE team was in April and lasted for 336 minutes (5 hrs. 36 Min.). The average on-scene time for the CARE Team during a client engagement has been 80 minutes per response.
Time on Task Data Points For CARE Team:
Transport Destinations Utilized with CARE Team December 16, 2021, to June 16, 2022 - 290 Client engagements, 37% transported and 63% did not require transport - 21 destinations utilized to support clients:
Transport Destinations Before CARE Team December 16, 2020, to June 16, 2021 - 166 Client engagements - 85% transported and 15% did not require transport - 11 destinations utilized to support clients, with all of them being clinical facilities: 
CARE Team Transport Destinations by Time Period Compared to Same Time Period from Previous Year - Including Transports to John George Pavilion (JGP), the Alameda County Psychiatric Hospital:
The same periods for the previous year before the CARE team was evaluated for calls for service for mental health responses and community members transported. According to the data collected during the first six months of the pilot program, the CARE Team responded to more calls for service with a significant reduction in clients transported. The transports directly to John George Pavilion remained consistent, but there was a reduction in client transports to other receiving hospitals in the county.
CARE Team Transport Comparison Before CARE Team vs. With CARE Team:
The initial outcomes for the 290 documented client engagements varied for clients that the CARE Team interacted with. The following initial outcome data was collected for responses as of June 16, 2022:
• 204 Referrals to Alameda Family Services without the need for any additional inventions other than the development of a Safety Plan.
• Four Clients were determined to need medical care and were transferred to an Advanced Life Support ambulance.
• The CARE Team transported 115 Clients to a destination (BART, hospital, family, etc.).
• 35 Clients were placed on a 5150 or 5585 psychiatric hold and transported.
• 18 Clients were evaluated; no treatment or transport was required.
• 38 Calls we canceled enroute or once arriving on scene-no client contact.
• 15 Clients refused the services of the CARE Team.
• Eight Calls the CARE Team was unable to locate a client upon arrival.
During the program's first six months, the Fire Department and Alameda Family Services partnership has been critical in allowing on-scene support, follow-up navigation, and wrap-around services. The first six months have provided 210 total referrals (six were directly received by APD) to Alameda Family Services. Of the 210 referrals, 163 of them were unduplicated client referrals. Following is a breakdown of the referrals and outcomes:
Alameda Family Services Referral Outcomes December 16, 2021, to June 16, 2022:
Alameda Family Services, to date, has served a diverse group of clients through their case management contracted services. Of the 210 clients referred for case management services, 44% were female, and 46% were male (10% either didn’t identify or the data was not recorded). Referred client ethnicity is reflected in the below chart along with overall age demographics for all contacts with the CARE Team field unit (Paramedic/EMT):
Gender Identification Comparison - Field Contacts Compared to Case Management Engagement:
Ethnicity Data Tracked by Alameda Family Services for Clients Engaged in Case Management (by quarter):
Age Demographics for All Client Contacts by CARE Team Field Units:
During the first six months of the Alameda CARE Team, AFS was utilized 108 times for on-call clinician services. Following is a breakdown of the reasons for requesting a consultation with AFS and the outcomes of the consultations. 5150 or 5585 psychiatric holds were issued for a total of 35 clients. 5150 is the number of the section of the California Welfare and Institutions Code that allows a person with a mental disorder and who is a danger to others or themselves or who is gravely disabled to be involuntarily detained for psychiatric hospitalization. A person on a 5150 can be held in the psychiatric hospital against their will for up to 72 hours. This does not mean that they will necessarily be held for the entire 72 hours; it means that a medical facility has the legal right to do so if determined to be necessary. California Welfare and Institutions Code Sections 5585.10 to 5585.25 provide for psychiatric holds for minors for up to 72 hours. A person can be held against their will in a designated facility only if they meet at least one of the three essential criteria listed: They are a danger to themselves, they are a danger to others, or they are gravely disabled.
Alameda Family Service on Call Contact Comparison (Reason for AFD consultation vs. outcome of consult):
After the first six months of the pilot, AFD worked with APD to coordinate data comparison and analysis of the impact of the CARE Team on APD operations and to evaluate the overall effect on meeting the program objectives. In the first six months, APD Computer Aided Dispatch (CAD) showed that they had been dispatched to 296 calls for service with client contact made. The CARE Team did not respond to six calls due to being unavailable. APD designates the CARE Team calls as either AFD5150 or PD5150 in the CAD. A call is coded as PD5150 if a weapon is seen or suspected and/or if the client is demonstrating or has verbalized a potential for being violent. All other requests for services are classified as AFD5150. During the first six months, 222 calls were categorized as AFD5150, and 74 were categorized as PD5150. During a PD5150 call, the APD Officer will first contact the client to ensure that the scene is safe for AFD personnel. On an AFD5150 call, AFD personnel will contact the client first, and APD will stage away from the incident and assist only if needed. They are released from the incident if APD is not needed to support AFD.
During the first six months, the time on task for APD Officers assigned to PD5150 calls averaged 154 minutes (2 hrs. 34 Minutes). On calls designated AFD5150, the average time APD was committed to the call was 38 minutes. The average reduction in commit time for APD when the CARE Team was primary was 116 minutes or 75%.
APD and AFD also evaluated APD calls for service and report taking before CARE Team and with the CARE Team. They analyzed the same time frame for calendar years 20/21 and 21/22. Before CARE, APD responded to 220 calls that were triaged as 5150 in nature, and 111 reports were completed. With the CARE Team program, APD has responded to 296 calls, and 37 reports have been completed. This data showed that in the first six months, APD increased calls by 29%, with a reduction of 66% in the requirement to initiate a police report due to the ability of the CARE Team to be the primary responder. Reduced report writing and on-scene times have allowed APD to increase availability for other service calls.
The first six months have returned some promising data in support of the CARE Team having the potential to impact the objectives established for the pilot program positively. The CARE Team continues to monitor several items to ensure the pilot meets the program objectives as it evolves. Some of the items identified include:
• The need to streamline data collection and track long-term results.
• Monitor how 9-8-8 impacts the program and continue to work closely with the 988 Alameda County Working Group as the community utilizes the new three-digit number. Also, continue to evaluate dispatch procedures and adjust as required.
• Identify potential state and federal funds to support the program long-term.
• Explore additional options to ensure we meet the First Responder’s mental health needs. AFS and AFD know this is a high priority and hope to develop a department Peer Support Program.
• Work with Alameda County Behavioral Health to identify ways not to duplicate services provided by their Mental Crisis Response Teams and the CARE Team. At the same time, ensuring clients receive appropriate Case Management follow-up and that client information is available to both resources that allow for longitudinal tracking of services provided.
• Ensure that AFD provides comprehensive pilot updates to the community and key stakeholders.
• Continue to train all AFD personnel to allow them to staff the CARE Team as needed and to provide a knowledge base that can be used when assigned to other apparatus (ambulances, fire engines, etc.)
ALTERNATIVES
Informational Report - Not applicable
FINANCIAL IMPACT
There is no financial impact from accepting this information report. Funding for the CARE Team in FY 2022-23 was previously appropriated by City Council.
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
Informational Report - Not applicable
Respectfully submitted,
Nicholas Luby, Fire Chief
Financial Impact section reviewed,
Margaret O’Brien, Finance Director
cc: Nancy Bronstein, Interim City Manager