A Crisis Resolution Center (CRC) is a facility that provides an important link in the continuity of care between long term hospitalization and completely independent living. It can serve as a less restrictive and more clinically appropriate treatment option for persons who are in psychiatric crisis but who do not need the medical capabilities of an acute care hospital, and it can result in significant cost savings.
Persons entering a CRC are typically referred by hospital emergency rooms or local mental health crisis teams (all arranged by contract ahead of time). It can be used as:
Ø An immediate alternative to acute hospitalization in an emergency situation
Ø An early intervention option for a person who is showing signs of decompensation
Ø A “cooling off” place for persons whose home situations have become intolerable
Ø A step-down from a period of acute psychiatric hospitalization facilitating smoother community integration or for hospital cost reduction
Ø As a place to monitor a person during medication changes or times of environmental flux.
Treatment is intended to keep the person safe, stabilize the person’s acute psychiatric symptoms, and return the person to their familiar living situation and treatment as soon as possible. Treatment usually entails a combination of Milieu Therapy, Psychotropic Medications, Solution Focused Brief Therapy, and Assertive Case Management.
CRCs can offer a great deal of flexibility to a community mental health program. The first is size. A facility for up to five residents is licensed as a Residential Treatment Home (OAR 309-035-0250). Facilities of six beds or more require licensing as a Residential Treatment Facility (OAR 309-035-0100). These facilities are commonly limited to 16 residents, as this is the maximum number of residents permitted to still qualify for Medicaid reimbursement. Ideally a CRC is built that will run just about full but rarely full. This allows for the most efficient use of staff and physical plant resources while still maximizing availability.
A second area of flexibility is the level of security for which the facility is built. The State of Oregon has rules for different “Classes” of facilities (OAR 309-033-0520) based on the level of restriction permitted on the person’s freedom of movement. Class 1 facilities allow for a locked facility and permit seclusion and restraint, including chemical restraints and the use of a state-certified hold room. Class 2 facilities do not allow for seclusion and restraint, but the facility is permitted to lock the exterior doors. Class 3 facilities are not locked; admission and discharge are voluntary on the part of the person, and the person must be released upon the person’s request (unless this presents a danger to themselves or others, at which time other legal means must be utilized). Each of these levels of security bring with them their own sets of rules on physical plant (such as sprinklers required for a five bed secure facility and any RTF but not for the others), staffing, and staff training.
A third area of flexibility is the use of crisis respite beds and residential beds. Crisis respite (OAR 309-035-0105 (11) and OAR 309-035-0260 (11)) is limited to stays of up to 30 days. In CCS’ experience, the typical length of stay is around three to five days, and OMHAS will typically grant a 30 day extension when it is clinically appropriate and no less restrictive alternative is available. A safe and low stimulation environment coupled with close medication supervision, solution focused treatment and case management is ideal for re-stabilizing acute psychiatric emergencies or serving as a professionally staffed support through domestic transitions. Transitional residential services can last several months, allowing for stabilizing persons with more enduring or intractable psychiatric issues and for the smooth transition of a person coming out of a State psychiatric hospital to less restrictive community living.
A fourth area of flexibility can be built into the physical design of the facility. With the right design, a facility can be built as a “free-standing” unit with a singular purpose or it can have different areas or “pods” for different populations and treatment issues. For example, ColumbiaCare Services built and runs a free-standing six bed Crisis Resolution Center Residential Treatment Facility in Coos Bay. This Class 3 facility is located adjacent to Bay Area Hospital and accepts clients 24 hours a day, seven days a week from Coos County Mental Health staff or directly from the hospital emergency room. ColumbiaCare Services is designing and building a 16 bed free-standing Class 1 Crisis Resolution Center in Klamath County, in part based on its success with the CRC in Josephine County. More common, however, is an intentionally designed facility with separate units for different populations within a coherent architectural design that provides for resident privacy but minimizes staffing expenses. ColumbiaCare Services facilities such as those in The Dalles and Boardman are examples of this: eight or nine residential beds coupled with three or four crisis respite beds. The two groups are separated from each other by sight and sound, but resources such as staff, supervision, meals, and maintenance can be shared. Please see www.columbiacare.org for photos and details of these facilities.
Any discussion of CRCs would be incomplete without serious consideration of treatment philosophy and practices, staff training, and supervision. For example, ColumbiaCare Services takes the “treatment” part of “residential treatment facility” seriously, and does not separate day-to-day operations of the facility from treatment. It is our expectation that all staff support the recovery of our residents and recognize that treatment and teachable moments can happen at any time. Staff is trained in basic skills as required by law, and in other complimentary methods such as non-invasive safety techniques, Applied Suicide Intervention Skills Training, evidence based practices supporting a recovery model, and how to faithfully document a treatment plan. Close, accessible supervision by experienced mental health professionals at the management level helps guide these activities and assures quality. Treatment should also be considered when thinking about “Class” or security level: security structure and procedures can affect treatment milieu and staff approach, and milieu and staff approach can dramatically affect the level of physical security necessary. Close cooperation with community mental health providers, hospital emergency rooms, hospital psychiatric units, and law enforcement is a hallmark for the planning and operations of a CRC.
Here are some examples of the utilization and cost savings from Crisis Resolution Centers and crisis respite beds embedded in residential facilities from ColumbiaCare Services experience; these bed days and cost savings are for the 12 month period January 1, 2007 to December 31, 2007:
Coos County 790 bed days $247,980
Wasco County 381 bed days $257,586
Curry County 228 bed days $120,030
