The 911 emergency phone number was proposed in 1957 by firefighters to provide people with an easy-to-remember number to reach the fire department. It wasn’t until the late 1960s, however, that AT&T – which operated almost all telephone connections in the U.S. then – established a 9-1-1 line.
Why 9-1-1? It was short, easy to remember, and unique and had never been used as an area code or other number. Nevertheless, by the mid-1980s, more than half of the United States was using it as the universal emergency number, and Canada soon followed.
In 1999 the Wireless Communications and Public Safety Act (911 Act) took effect directing the FCC to make it the universal emergency number for all phone services. Since its inception, millions of lives have been saved because of the effective and efficient way it is used to connect individuals in need with emergency professionals promptly.
Though 911 is an effective means of dispatching emergency personnel to a crisis, misuse of the number does occur. Police departments across the country report a growing number of inappropriate calls to 911.
Many involve situations that are not real emergencies that could be better addressed by direct calls to police or medical facilities. But unfortunately, there also exists what has become known as “super-utilizers” – people who account for a disproportionate number of calls for the same issues, many involving behavioral health concerns. In jurisdictions across the nation, law enforcement is working to determine how Crisis Intervention Teams can address this 911 super utilization.
Characteristics of a Super Utilizer
In simple terms, a super utilizer is defined as an individual who uses Emergency Medical Services at excessively high rates. A study in the Annals of Emergency Medicine defines super utilizers as “Individuals visiting an emergency department four or more times per year.”
The review stated that this accounts for 4.5% – 8% of all emergency department patients and 21% – 28% of all emergency department visits. In addition, these individuals are more at risk of drug and alcohol abuse and mental health issues.
They represent a unique and crucial need within the behavioral health continuum. Experts suggest that these individuals are often better served in settings other than emergency rooms, where appropriate and consistent medical or social services may be provided.
The frequent use of emergency departments by these super users contributes to inefficient healthcare spending and high healthcare costs. Some estimates suggest that eliminating revisits and inappropriate emergency department use could reduce healthcare spending by as much as $32 billion annually. A research project was conducted by the Agency for Healthcare Research and Quality (AHRQ) to study the vulnerabilities of patients at the highest risk of frequent emergency department use and determine how they might be addressed during their visits. The findings included the following:
- Close to 10 percent (9.1%) had a history or current chief complaint of substance abuse
- About 33% had a history of schizophrenia, bipolar disorder, or psychosis
- Nearly 40 percent (39.6%) did not understand which symptoms might signal a need to seek prompt medical attention
- Nearly half (48.7%) took four or more medications
- More than half (56%) did not understand their discharge instructions
A significant implication of the findings determined that revisits may be driven by factors not readily addressed by emergency departments. Instead, reductions in their frequent use will require strategies beyond the capacity of emergency departments alone. A viable solution is the implementation of Crisis Intervention Teams, which can help patients navigate the health care system and receive more appropriate treatment.
Identifying Super Utilizers
The ability of law enforcement to identify 911 super utilizers before arriving on the scene of a crisis can save valuable time and provide vital information critical to the outcome of the encounter. Knowing that an individual is considered a super user can help CIT officers be more sensitive to the individual’s needs and enhance their ability to determine appropriate next steps.
In many communities, emergency responders cannot communicate with each other and share critical patient information regarding the frequent users, possibly resulting in their needs being left unmet. Their uncoordinated approach means a person’s likelihood of appropriate treatment and successful recovery is limited, especially for those in vulnerable situations.
A robust technology platform like Julota can help communities identify their highest utilizers across disparate systems to align resources better to improve outcomes. In addition, its cross-system data sharing strategies can help to coordinate care among providers and break the cycle of costly incarceration, improving outcomes for these “familiar faces.”
With Julota’s cloud-based solution, organizations can define criteria to identify 911 super utilization, such as contacts made within a certain period. In addition, key indicators such as mental illness, substance use disorders, chronic homelessness, or other social or medical situations can provide a high-level data snapshot of the mental health or substance use status of individuals served and the outcome of encounters.
Training 911 Dispatchers for Mental Health Related Crisis and 911 Super Utilization
911 dispatchers have been quoted as “the invisible first link in the chain of first-responder work.” (Stephanie Conn, Ph.D., of First Responder Psychology). As that first link, dispatchers play a vital role in identifying emergencies involving people with mental health issues, substance use disorders, or intellectual disabilities.
One of the Core Elements of CIT programs states that “dispatchers should be trained to appropriately elicit sufficient information to identify a mental health related crisis.” As a result, CIT International now offers a course for 911 call-takers to prepare them to identify crisis calls, understand their role in triaging the calls, and begin the de-escalation process.
Many crisis intervention teams across the country are also beginning to understand the need for proper training. For example, the Phoenix Police Department’s Crisis Intervention Team offers training to 911 dispatchers to identify types of mental illness, assess threat levels, utilize negotiation tactics, and learn where to direct callers for appropriate help. The Police Department has several hundred CIT-trained officers and two full-time squads collaborating with local behavioral health partners.
In 2019, California became the first state to initiate mental health awareness training for all 911 dispatchers. Although it did not become law, the Commission on Peace Officer Standards and Training (POST) voluntarily implemented the program. Assemblymember Kansen Chu (D-San Jose) worked with the National Alliance on Mental Illness (NAMI-CA) to push for better training on mental health identification for 911 dispatchers. Assemblymember Chu: “Mental health support for those in need is a priority for me, and I’m glad it’s also important to POST…this training will help alert responding officers to special circumstances, such as mental health crises. I want individuals with mental health struggles to get the help they need instead of being locked up.”
Use of Technology in Addressing 911 Super Utilization
In May 2015, President Obama’s Task Force on 21st Century Policing released its final report. In its Executive Summary, the task force stated: “Trust between law enforcement agencies and the people they protect and serve is essential in a democracy.
It is key to the stability of our communities, the integrity of our criminal justice system, and the safe and effective delivery of policing services.” Recommendations from the Task Force included six “pillars” consisting of Building Trust and Legitimacy, Policy and Oversight, Technology and Social Media, Community Policing and Crime Reduction, Officer Training and Education, and Officer Safety and Wellness.
The pillar of Technology and Social Media included the need for integrated data systems among health and criminal justice sectors to identify repeat users of community resources and interventions before crises happen. In addition, standards for technological solutions should address compatibility and interoperability within law enforcement agencies and partner agencies and maintain civil and human rights protections.
Julota is the ideal solution for providing these standards. Its interoperability function can automate collaboration between emergency responders, clinical professionals, and partner agencies. Its secure, cloud-based platform transcends the barriers of security, privacy, and consent management. The vital data collected meets all HIPAA guidelines and will remain secure and out of the view of unauthorized parties.
Emergency care is integral to providing quick access to care for individuals with acute medical needs. However, super utilization of emergency departments can be challenging for medical professionals and law enforcement. The question then becomes: “How Can Crisis Intervention Teams Address 911 Super Utilization?”
As mentioned in this article, identifying these individuals with a robust technology solution is an essential first step. It is also vital that 911 dispatchers receive the proper training to assist them in eliciting the information needed from individuals to identify a behavioral health crisis quickly.
Suppose the Crisis Intervention Team has this information when responding to a situation. In that case, they will be better equipped to de-escalate the situation and see that the individuals receive the appropriate treatment. Evidence shows that using Crisis Intervention Teams in these encounters has proven to be an effective and safe solution for everyone involved.