SRVFPD: Mental Health Calls Have Increased 90% in 2021
SAN RAMON – Last Tuesday, San Ramon Valley Fire Protection District (SRVFPD) staff presented their proposed mental health response initiative to the San Ramon City Council. The stated goals of the initiative are to treat some mental health calls as medical calls, decrease the number of mental health committals under Welfare & Institutions Code 5150, provide a higher level of care to mental health patients and encourage patients to seek help sooner for mental health issues.
Background
SRVFPD’s new mental health response program was announced on the heels of a 30% increase in mental health-related calls in the San Ramon Valley during 2020. Based on early projections from SRVFPD, these calls will increase by 90% in 2021. The agency is the San Ramon Valley’s primary emergency medical services (EMS) provider; their stations are staffed with Firefighter/Paramedics who can respond to fire and medical-related calls. Although the agency provides services for the San Ramon Valley, last Tuesday’s presentation only focused on how the district would provide services to patients in San Ramon.
Under existing mental health response practices, once a call is received, a dispatcher can determine if a caller is reporting a mental health-related emergency. This can range from a welfare check to a violent crisis; for these calls, whether violent or non-violent, police officers are dispatched. Once at the scene, officers ensure the scene is safe for additional resources, such as paramedics. Officers may choose to evaluate the patient in crisis and determine if they meet the criteria for a mental health hold (as defined in Welfare & Institutions Code 5150). This evaluation is typically performed to determine whether a person is a danger to themselves or others, or is gravely disabled and unable to care for themselves. Under W&I 5150, only a police officer or designated mental health professional can commit a patient for a mental health hold. If the subject meets the W&I 5150 criteria for a hold, officers in the San Ramon Valley usually request EMS personnel (SRVFPD or private EMS service) transport the patient to a county medical facility. Once at the county medical facility, a mental health professional evaluates the patient and determines if they will be admitted to the facility. State law prevents the facility from holding a patient for longer than 72 hours in most circumstances.
Under SRVFPD’s new initiative, paramedics would receive mental health-related training. Dispatchers would triage calls and determine if the subject is experiencing a non-violent, low-risk mental health-related issue. This call would be routed to paramedics for their response. Once at the scene, the district says their plan would “flip the script” by having paramedics contact the patient first, while police “stage” outside or nearby. After the initial patient interaction, paramedics would determine the appropriate treatment. The district says treatment can include transporting the patient to a mental health professional at a local hospital, transport to the county medical facility, or involving the county’s mobile crisis response team. The district says police officers would be requested to enter the scene in situations that become escalated or violent.
SRVFPD says the new system would provide a higher level of care to patients experiencing de-escalated, non-violent mental health episodes. By treating these types of calls as medical-related instead of law enforcement-related, the new approach would aim to transport patients to a medical facility, such as a local hospital with a mental health professional. So-called “frequent flyers” may also be transported to a local hospital where they see a familiar doctor, allowing long-term treatment monitoring. The district also believes that by removing a gun and a badge from the situation and giving a patient a more comfortable environment (like a local hospital) than the county medical facility, fewer patients would be placed on mental health holds. This environment, the district says, would allow patients a more direct route to mental health professionals, ultimately making patients comfortable with seeking care for mental health issues and destigmatize the process.
The program would also aim to supersede the county’s newly formed mobile crisis response team, which responds to mental-health-related emergencies throughout the county. The county-based team is staffed by designated mental health professionals who are sometimes accompanied by police officers. SRVFPD believes their service would be advantageous in some instances because of their ability to transport patients to a local hospital and their quick response time. The county team expects their response times to average 30 minutes, while SRVFPD’s typical response time to any medical emergency is 7 minutes. The county team is only available during certain days/hours while SRVFPD’s personnel are available 24/7. Representatives from both SRVFPD and San Ramon Police also expressed concern that the county’s mobile crisis response team will be too burdened by calls within the county to provide a consistent level of service to the San Ramon Valley.
For reading purposes, the Analysis section of this article should be regarded as opinion.
Analysis
While SRVFPD’s plan is progressive and could yield significant benefits for the community, it leaves the door open for increased risk and liability for first responders and citizens. Under California law, only police officers or designated mental health professionals can determine if someone meets W&I 5150 criteria, often referred to as “danger to self or others.” Under the district’s plan, which aims to decrease the number of W&I 5150 holds, paramedics would be tasked with performing an analysis of the patient’s mental status. If paramedics believe the patient is a danger to themselves or others, police would be requested to the scene to perform an evaluation under W&I 5150. However, paramedics could also determine the patient is not a danger, despite lacking the legal authority to make that determination, and proceed with an alternative form of care without involving a W&I 5150 evaluator at the scene.
Both fire and police personnel agree that sometimes patients receive better long-term care in a clinical setting versus the county medical facility (CCRMC) for a 72-hour hold. Whether the patient is transported to a local hospital or a county facility, they would be seen by mental health professionals who are authorized, like police officers, to use probable cause and determine if a person meets W&I 5150 criteria. The district says that a patient who is transported to a local hospital is more likely to become de-escalated than a patient transported to the county medical facility because the hospital and familiar doctors create a more comfortable environment. The thinking is patients would be calmer when they are evaluated at a hospital. In situations where they could have been determined a “danger to self or others” by a police officer at the original scene, they would no longer meet W&I 5150 criteria once they are calmed at the hospital.
However, mental health is a complicated and dynamic issue. Patients can become escalated and de-escalated for a specific external reason, or no reason at all. Part of a W&I 5150 evaluation is to determine if a person is a danger to themselves or others at that moment in time, as a patient’s mental state can shift as they arrive at a hospital, but re-escalate once they are released. The evaluation of a person’s mental state during a crisis is particularly important – California “red flag” laws regarding firearms rely on W&I 5150 evaluations during a mental health emergency. If a patient is held under W&I 5150, state law prevents them from purchasing a firearm for several years. It is possible that a paramedic, without having a legal authority under W&I 5150, determines a person is not a “danger to self or others” and proceeds with an alternative care method, whereas a police officer, given the same circumstance, would have placed the patient on a W&I 5150 hold. Under SRVFPD’s initiative, this patient could be seen by a mental health professional at a hospital in an already de-escalated state, and that patient could be released from the hospital, having never been admitted under W&I 5150, later escalate their crisis, and purchase a firearm. If this unlikely scenario were to take place, it would expose the community to risk in a situation that would have been preventable through existing state laws and processes.
Additionally, one of the program’s stated goals is to remove police officers from a situation that involves a de-escalated and non-violent mental health call. However, in the above situation, or if the patient is later determined to meet W&I 5150 criteria by a hospital mental health professional, because police officers were never inside a residence, they lose access to a critical law drafted to prevent tragedy: W&I 8102(a) allows peace officers to, once the patient has been determined to fall under W&I 5150 criteria, seize firearms that a patient has access to. Without ever being present at the scene (staged outside as part of the new plan), it becomes difficult for officers to enforce W&I 8102(a) in hindsight if the patient was admitted under W&I 5150 after the fact (at a hospital). According to San Ramon Police Captain Denton Carlson, because officers never entered the scene in this situation, they would have minimal liability. SRVFPD Chief Paige Meyer says liability is a part of any EMS agency and the district will perform a risk/reward analysis. He added the district believes police officers sometimes commit patients under W&I 5150 only due to liability concerns – thinking ‘what-if’ something happens if they are not held for 72 hours. Chief Meyer says the new program would remove that burden from police officers.
The program also relies on the caller to relay accurate information to a dispatcher – specifically, whether the patient is in a de-escalated, non-violent state and not in possession of weapons. Chief Meyer agreed is not uncommon for 911 callers to provide information that is erroneous, sometimes placing paramedics in hazardous situations. However, he says this is a possibility on all medical calls, and paramedics are trained to remain safe on these calls, whether it’s a diabetic emergency or heart attack. Chief Meyer said when patients are treated by paramedics, many of them also suffer some sort of mental health issue, such as anxiety, due to the medical emergency they are experiencing. He added that dispatchers will have access to a patient’s criminal history and address history when dispatching a call, allowing previous contacts to be considered during the hazard assessment.
San Ramon Valley Fire Protection District’s new mental health response initiative could bolster the level of care that mental health patients receive and provide a medical-based clinical approach to certain calls. The initiative is one of the ways in which California first responder agencies are re-thinking their response to mental health emergencies with the goal of improving patient outcomes. As many agencies adopt medical-based responses to mental health calls, state laws should be amended to give paramedics legal authority to make decisions regarding mental health treatment under W&I 5150.
