What Texas can learn from crisis mental health care in Arizona

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After a call for police assistance with a mentally ill man at a Tucson gas station turned deadly, resulting in the deaths of the responding sheriff’s deputy, the man, and a cab driver who stopped to assist, local leaders began work in 2005 on a better way to respond to people in crisis.

It was a multiyear endeavor. Local voters passed a $15 million bond to fund the construction of Tucson’s new 24/7 crisis center where individuals could get immediate behavioral health care. An entire remapping of how officers would respond was designed to de-escalate encounters with individuals in crisis. Instead of taking mentally ill individuals to jail or hospital emergency rooms, officers could bring them to the new crisis center, where staffers would quickly work on a patient’s diagnosis and treatment. Law enforcement officials served on the crisis center's board and helped lead its design.

But seven months before the crisis center opened its doors, another tragedy involving a suspended community college student unfolded. The 22-year-old in that 2011 incident, later diagnosed with paranoid schizophrenia, opened fire on 19 people in a supermarket parking lot, killing six and critically injuring then-Congresswoman Gabrielle Giffords.

The shooting brought a new urgency to Tucson’s efforts.

“All of the ideas were maturing when this horrible thing happened,” said Tuscon Police Sgt Jason Winsky, a supervisor of the mental health support team member for the department. “Everything kind of accelerated in 2013 and 2014, and we were lucky to have those resources just coming online at the same time.”

Today, Texas leaders are looking to Tucson for ideas on building an effective crisis care system for mental health. Tucson is the inspiration behind a new crisis care model underway in Travis County.

“If we had a robust crisis service center like Tucson, it would change Austin and Travis County overnight,” said Travis County Judge Andy Brown.

Lessons learned

Before Giffords’ shooting, the Arizona mental health system, over time, had undergone a budget cut of $108.4 million between 2009 and 2011, resulting in far reduced services. Texas underwent something similar in 2003 when lawmakers cut the community mental health funding by $100 million due to economic concerns. This affected how many mental health services were readily available to the public in both states.

The 2005 incident that spurred action in Tucson occurred after a man in the midst of a mental health crisis had been dropped off by police at an emergency room and was released within hours. He walked to a nearby convenience store and began interfering with customers. A Pima County deputy was called out, and the man became combative, running into the adjacent highway as he was being handcuffed. The deputy and a cab driver attempting to help the officer followed. All three were killed by oncoming traffic.

While deadly interactions had occurred before, this one incident spurred Tucson leaders to action. They tapped a combination of federal, state, and local funds and the input of their community to overhaul the existing police response.

“We got the opportunity to express our needs for the center,” Winsky said. “It had to be low-barrier, and it had to be 24/7. You have to take people who are angry, intoxicated, and involuntary, and that is the area we knew most places (medical facilities) don’t do.”

By adopting a “no wrong door” treatment culture, Tucson created a one-stop, coordinated system of care. Since 2003, the U.S. Health and Human Services’ Administration for Community Living, which supports the needs of aging and disability populations, has provided grant funding to 33 states to plan and implement a “no wrong door” system to make it easier for clients to access the services they need.

How states use the “no wrong door” concept varies from state to state. In Arizona, it refers to the ability of law enforcement to drop off anyone they suspect suffers from mental illness at a crisis response center in under 10 minutes.

In 2009, two years before Tucson’s Crisis Response Center opened, Connections Health Solutions was created and assumed ownership of the Phoenix Urgent Psychiatric Center. In 2014, they assumed management of the Tucson facility and helped turn both into two of the nation’s largest and most studied crisis response centers.

Today, Tucson’s center now treats 12,000 adults and 2,400 youth annually. Services include 24/7 walk-in urgent care, 23-hour observation, crisis stabilization services for adults, and a police drop-off point.

“Now, with every single call that an officer goes on, they know no matter what condition the person might be in, there is a crisis center that will say ‘yes’ to taking them in,” Winsky said. “This is how a culture changes.”

A time for change

There are many crisis centers across the country, including in Texas, but what separates Arizona from everyone else is their ability to send anyone who might be undergoing a mental health crisis to their local crisis centers, even without their consent.

Travis County, in partnership with county mental health provider Integral Care, launched the first phase this year of its version of a jail diversion program with a $23 million three-year pilot program.

By September, Integral Care will expand its services at its walk-in clinic on Airport Boulevard to 24/7 care and add a new 23-hour observation service for people at risk of harming themselves or others. The county will also repurpose Austin’s former Ronald McDonald House as a 25-bed, 90-day-stay therapeutic diversion program for those needing long-term stabilization and housing.

First responders can use an entry point at the walk-in clinic similar to the one in Tucson to drop people off and receive a clinical assessment to determine their care level. However, the program in Travis County has limits.

This Integral Care program is voluntary, meaning first responders would need to take someone who is too intoxicated for an assessment to a place where they can detox before they can be transferred to their clinic. The same goes for someone who might have too severe of a mental illness, as this program is meant for only those who might need a place to stabilize. This means officers in Travis County have to choose which facility might accept someone with mental illness.

This is not an issue for the crisis centers in Arizona as law enforcement can drop off anyone without them volunteering and at any stage of a mental health crisis, and anyone can come to the facility for treatment as well.

“That piece is important because, without this ability, the whole system is a jigsaw puzzle,” Winsky said. “You have this place that won’t take people if they are too intoxicated, or this place won’t take them without insurance. We aren’t insurance authorizers or claims and billing. We are law enforcement. That is why law enforcement will always choose the easiest option; for many states, that is the jail.”

Brown said Tucson's ability to have housing, mental health, medication, and detox all in one facility is what separates it from Texas. He said that services being separated across various agencies around the county makes the mental health system in Texas disjointed and confusing for residents and law enforcement.

“There are other places around the state that follow the same model as Tucson, and they are starting to see success,” Brown said. “I recently went to Lubbock, and their plan is excellent.”

Earlier this year, the local leadership in West Texas broke ground on a new mental health diversion center with a mental health drop-off point for first responders. For those who need long-term help, StarCare’s Sunrise Canyon Hospital is right next door.

This facility is part of the West Texas Mental Health Collaborative, which includes the City of Lubbock, Lubbock County, University Medical Center Health System, Covenant Health, Texas Tech University, Texas Tech Health Sciences Center, and StarCare Specialty Health System, whose goal is to improve coordination of mental health services in the area.

West Texas isn’t alone in looking into crisis centers that house much-needed community services near each other or under the same roof.

Galveston County is set to open a new mental health crisis center this year. The center will have 10 extended observation units and 10 respite beds, along with clinical staff who will coordinate care, provide discharge medication, and, if necessary, coordinate long-term hospitalization.

Gov. Greg Abbott also announced this year a $34 million project to build a behavioral health campus in Uvalde dedicated to providing on-site care to children and adults experiencing mental health crises in 32 surrounding counties.

“This new behavioral health campus will provide Texans experiencing a mental health crisis with access to mental health professionals and around-the-clock treatment to address their needs,” Abbott said in a news release.

This regional facility will feature a 16-bed crisis unit for adults and a 16-bed crisis unit for children. The campus will act as a 24/7 diversion center, accepting walk-ins and drop-offs from law enforcement.

These new facilities all align with the “no wrong door” model, which allows for easy access by law enforcement and the public. Brown, the Travis County judge, believes now is the time for Travis County to join the growing crowd.

Eventually, Brown plans to build a crisis center similar to Tucson's. He hopes to seek bids for such a structure by the end of the year. But it’s not clear when construction would start or be completed. The county is considering whether to renovate existing facilities or construct a new central booking facility with a diversion center attached this year.

County officials are hopeful a more permanent structure will be ready to open by 2029 or 2030.

“I know the state has been aggressive when it comes to mental health, so hopefully we can agree with what to do here,” Brown said.

Medicaid expansion impact in Arizona

Politically, Texas and Arizona have long leaned conservative and residents in both states have elected Republican presidents for years.

But despite its GOP bona fides, Arizona took the leap in 2013 and joined the majority of states that have since chosen to expand Medicaid coverage to more low-income residents. Texas is one of a handful of states that has refused to expand Medicaid coverage to all low-income adults who could qualify. If Texas did expand Medicaid, it would bring more than $5 billion in new federal dollars to the state and another 1 million Texans would qualify for health insurance coverage.

The impact of that expanded Medicaid coverage in Arizona was certainly noticeable to Margie Balfour, a former Texan who worked in mental health at Parkland Hospital in Dallas, who moved to Arizona to help run the crisis center in Tucson.

“All I saw was these Medicaid-funded programs, and it took me by surprise,” said Balfour, now the chief of quality and clinical innovation for the Arizona-based Connections Health Solutions and an associate professor of psychiatry at the University of Arizona.

That extra funding is the envy of local health officials in Texas.

“They just have more funding than us because of it, and our Texas legislators refuse to do it,” Brown said.

To boost local mental health care budgets in Arizona, officials bundled Medicaid and federal block grants with state and local funds.

In 2015, Arizona began providing services for residents with serious mental illness in counties other than Maricopa County under three regional behavioral health authorities. A year later, the Division of Behavioral Health Services moved from the Arizona Department of Health Services to the Arizona Health Care Cost Containment System, which administers the state’s Medicaid program.

“Most states have a Medicaid department and a separate department for mental health. The Behavioral Health Department gets federal block grants, and others get Medicaid funding, and you hope it trickles down,” she said. “Arizona has combined them, and it all runs through AHCCCS.”

This funding model allows crisis centers to take on anyone, knowing that one of the three revenue streams will cover the cost.

“It’s a pay upfront model,” she said. “You are paying people to be available at 2 in the morning and to be on standby. Then, the accounting on the backend is done to see which stream will be used for the services.”

It also allows for immediate treatment, meaning a person can be dropped off at a crisis center, stabilized, and receive medication within 24 hours.

“We can do groups and peer therapy and detox protocols. Our case managers are on the phone with clinics and hospitals with the goal to get them back into the community,” Balfour said. “After 23 hours, we reassess, and most go back to the community after that time without ever seeing a jail or hospital.”

Texas is on the right path regarding the “no wrong door” model, but Balfour believes it could be done easier and quicker if lawmakers chose Medicaid expansion.

“Ultimately, Texas needs to expand Medicaid,” Balfour said. “Look at the work done in Arizona by Republican governors and legislators. A true fiscal responsibility to the people means it only makes sense to accept Medicaid because if not, you are just leaving money on the table.”

Local mental health access in Texas

Texas has been credited as one of the significant contributors to the “no wrong door” model used in Tucson. The founders of this concept at Connections Health Solutions helped create the first crisis unit to serve the needs of the public mental health system in Tarrant County and credit their time in Texas as the start of their plan.

However, this is where the similarities between the two state mental health programs end.

In Texas, emergency rooms are often the first option for someone dealing with a mental health crisis due to a shortage of psychiatrists and a lack of providers who accept insurance in general, as many have gone to cash only. This has also narrowed the options for where law enforcement can go when they come into contact with someone undergoing a mental health crisis, meaning jail is often the quickest option.

Here, local mental and behavioral health authorities have community-based crisis programs that may include crisis stabilization units, short-term hospitalizations, and detox services. But again, finding them requires a lot of phone calling, Google searching and emails.

That’s because not all counties have access to each facility type; therefore, most Texans need to contact local mental health agencies beforehand to see what is available.

Texas requires all 39 local mental health authorities to operate crisis hotlines and mobile crisis outreach teams in their communities, which serve as an immediate point of contact.

However, many clinics are volunteer-only or lack the staff or facilities to treat severe mental illness. Because demand is high, first priority is often given to the uninsured or underinsured Texan. Also, Arizona has only 15 counties – compared to Texas’ 254 making it harder to build regional crisis centers here.

Unlike Arizona, Texas doesn’t have a central location for all community services. Behavioral health might be handled by one local agency while a different organization handles housing, and these facilities might be miles away from each other. The Texas mental health system is also set up to give counties the freedom to address their community's needs with the funding available to them. This means the services available might vary depending on the zip code someone lives in.

“Our system is too convoluted,” said Brown, Travis County’s chief executive. “You have places that only accept certain people, open at a particular time, or only take a certain type of insurance. That is how you get what we see today.”

In 2022, the Texas Health and Human Services Commission received a grant through the Administration for Community Living to examine this state’s “no wrong door” system.

“Through this grant, HHSC is using several methodologies to define and map the NWD system as well as identify opportunities to improve the system,” said James Rivera, an agency spokesperson.

Rivera said the health agency will submit a final report to the Administration for Community Living by the end of this month, and its findings and recommendations will be shared with the public.

“HHSC will continue to refine our NWD system by considering the implementation of best practices which may include a review of other state’s plans,” he said.

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