Reinventing EMS response to substance abuse, mental health emergencies

St. Charles County Ambulance District has armed medics with screening tools and additional EMS training to get patients to appropriate definitive care


Nationwide, 10% of all 911 requests for police are mental health related [1]. A typical response to mental health emergencies consists of police entering the scene first and ensuring it is safe for other responders, such as EMS. Police officers often are the first to encounter these individuals, although they are generally provided minimal training related to mental health emergencies.

Behavioral healthcare is much more than a policing issue. In the wake of George Floyd’s death, many cities and communities called for defunding, or re-allocating, portions of police budgets to combat other growing problems in society, such as addiction and homelessness. Mental health contributes to both.

It’s also not surprising that mental health issues are one of the fastest-growing healthcare needs in the U.S., with 1 in 4 adults and 1 in 5 children experiencing a mental-health incident in the past year [2], according to the federal Office of Disease Prevention and Health Promotion. The report also highlights the nationwide increase in suicides during that period in the last 12 months.

mental health issues are one of the fastest-growing healthcare needs in the U.S., with 1 in 4 adults and 1 in 5 children experiencing a mental-health incident in the past year [2], according to the federal Office of Disease Prevention and Health Promotion. (Photo/Getty Images)
mental health issues are one of the fastest-growing healthcare needs in the U.S., with 1 in 4 adults and 1 in 5 children experiencing a mental-health incident in the past year [2], according to the federal Office of Disease Prevention and Health Promotion. (Photo/Getty Images)

Pivoting toward change

Is it time to reinvent public safety response to mental illness? Many communities are moving toward change.

Community leaders advocating for defunding police note this does not mean the end of policing, but instead that a portion of overall police department budgets would be allocated to pay for other community service initiatives.

While cities such as San Francisco and Baltimore are still determining where that money would be best spent, city leaders in Athens, Georgia, have already made public recommendations. A proposal to fund the recruitment and training of mental health social workers and a mental health first responder team available around the clock was brought before the City Council in June. The proposed mental health resource teams would have been considered police department personnel, but not sworn law-enforcement officers. However, the proposal was voted down [3-5].

Shifting the mental health emergency model

Other communities have had more success in shifting their approach to mental health emergencies. The emergency medical service in St Charles, Missouri, has successfully developed and implemented an innovative approach to bring the physician or therapist to the scene of a mental health emergency [6].

Sadly, an all-too-frequent scenario is the scene of a drug overdose. EMS first responders do everything in their power to save the patient, but it is too late. Imagine the seasoned paramedic’s frustration when he turns to his partner and says, “I am tired of telling parents their son or daughter has died, and I am tired of telling children their father or mother has died!”

Scenarios like this were happening time and again in the St. Charles County Ambulance District (SCCAD), and they have became a strong motivator for the team to rethink the model for EMS response to drug overdoses.

And that was how the Substance Use Response Recovery Team concept was born. SCCAD paramedics, with the guidance of the Substance and Mental Abuse Services Administration, worked diligently beginning in March, 2017, to create a new approach to tackle the drug epidemic.

SCCAD created a HIPAA waiver to allow specialty trained paramedics to work with substance use disorder patients – SCAAD’s preferred term for drug overdose patients – who were revived after an overdose event. It was noted that the patients were the most lucid and aware of the significance of their problem immediately after regaining consciousness. Before the paramedic leaves the patient, patients who are interested in the program are asked to sign the HIPAA waiver and are contacted within 48 hours to help navigate them to appropriate treatment.

Stepping up mental health education for EMS providers

Additional education was critical in implementing the St. Charles County program. All paramedics are educated in substance use disorders to reduce stigma and increase their understanding of the medical considerations. In addition, specialty team members are provided initial training including Missouri Recovery Support Specialist, crisis intervention and motivational interviewing training. Team members are also encouraged to take the Missouri Community Paramedic Certification (approximately 70 hours classroom and 50 hours of clinicals).

The program has been an overwhelming success, and for the first time since 2014, overdoses in St. Charles County declined in 2019 by 19%.

County officials recognized a similar challenge existed in St. Charles County’s hospital emergency departments. Patients were transported to local EDs, only to wait for confirmation by physicians that they were not in an emergency medical state related to mental or behavioral health issues. Sometimes a needed meal or a more comfortable environment was provided, but all too often, the main issue remained untreated.

Due to the lack of immediate treatment facilities for lower level behavioral health issues, patients would spend unnecessary and expensive hours in an ED, only to be released with no significant change in their healthcare needs.

St. Charles County Ambulance District decided to tackle the problem and find a better solution for everyone involved. They determined paramedics could confirm patients were not in a behavioral emergency and connect that subpopulation of patients with a clinician better suited to truly treat their conditions. Paramedic education armed the responders with a new tool: the SEA-3 Mental Status Exam, which assesses speech, emotion, appearance, alertness, and activity [7].

They were also trained to utilize the SAFER-R model [8]:

  • Stabilize. Calm environment, professional, make patient feel safe
  • Acknowledge. Evaluate situation, gather information, be empathetic
  • Facilitate. Determine if patient is cognitive, assist family members, pass on helpful info
  • Encourage. Continue to build rapport, re-orient patient and family, explain your concerns, encourage actions in patient’s best interest
  • Recovery. Reinforce that patient is in good hands and review transport plan
  • Referral. Assist patient and family to identify additional resources, recommend additional crisis intervention services and/or professional care

Data-driven results

SCCAD collaborated with Behavioral Health Response to put patients who met the criteria into a telemedicine visit with master-level behavioral health clinicians. The team coordinated care for the patients to find the best option for their current conditions. The following results occurred:

  • 25% of behavioral health calls met established criteria
  • 81% of patients evaluated by telemedicine were not transported

The program has been well received. Patients receive far more effective and appropriate treatment, and ambulance crews do not transport patients unnecessarily into already busy EDs that are not well-suited to address the patients’ conditions.

As communities across the nation adapt to the increase in demand for better mental health care, the clear message is that the need for change exists and that EMS systems may be an effective and efficient source for solutions.

Read next: De-escalating mental health/substance abuse crises

About the authors

Kelly Cope, assistant chief of operations, St. Charles County Ambulance District; Tony Fauci, operations manager, National EMS; Tony Lowery, training coordinator, Priority Ambulance of Tennessee; and, Christina Kiley, operations manager, Maricopa Ambulance, are members of the Priority Ambulance Leadership Foundation 2020 class.

References About the authors

  1. Governing.com, Public Safety & Justice. “The Daily Crisis Cops Aren’t Trained to Handle.” May 2016.
  2. Healthy People 2020. Leading Health Indicators 2020 – Mental Health.
  3. Georgia Public Broadcasting. June 17, 2020.  
  4. The Red & Black. June 20, 2020.
  5. Fox 5 Atlanta. June 26, 2020.
  6. St. Charles County Ambulance District. Georgia Public Broadcasting. June 17, 2020.  
  7. AAOS Prehospital Behavioral Emergencies and Crisis Response by Dwight A. Polk, MSW, NREMT-P; Jeffrey T. Michell, PhD; Benjamin Gulli, MD.
  8. The SAFER-R Model: Psychological Crisis Intervention by George Everly Jr. Published by the International Critical Incident Stress Foundation, Inc. 2017.

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