With Emergency Triage, Treat and Transport, the U.S. Centers for Medicare and Medicaid Services covers emergency medical response providers transporting patients to an alternative facility, such as a primary care office or community mental health center. ET3 also covers emergency responders to initiate treatment in place with a qualified healthcare partner – either at the scene or through telehealth.
The ET3 model also encourages local governments and other entities that have authority over one or more 911 dispatches to promote and establish a medical triage line for low-acuity 911 calls and reduce avoidable transports to emergency departments and hospitalizations, according to Justin Miller, vice president of customer success at eVisit, a telemedicine technology and services company.
“Navigators help triage folks who have called 911 and have entered the emergency response pipeline by first ascertaining if they are eligible for a telehealth call or an actual emergency visit,” he told Healthcare IT News last year.
“The dispatcher connects the caller to a nurse who will seek to understand the patient’s concerns and connect them to the right provider before they even send out the ambulance crew. The focus is on delivering the right level of care at the right time,” he said as he traveled the country to observe telehealth later in the pandemic.
As a federally funded five-year pilot project, ET3 aims to make emergency medical care more accessible. However, CMS has announced an early end to ET3, two years early – effective December 31.
“This decision was made due to lower-than-expected participation and lower-than-projected interventions,” CMS recently announced on its ET3 website.
“Emergency Medical Services remain an area of focus for CMS, and we believe that the lessons learned from the ET3 Model can aid in the development of potential future initiatives.”
Meanwhile, one California campaign is lobbying to shift the responsibility for certain 911 calls to the healthcare sector, based on the success of public safety dispatchers initiating clinical triage by nurses in mobile crisis units, according to the following article by Molly Castle Work, writing for KFF Health News.
A mountain of evidence shows police often fail to respond properly to people experiencing a mental health crisis. It can lead to avoidable deaths and criminalization of mental illness, especially among people of color.
A poll commissioned by Public Health Advocates, a Davis-based health policy nonprofit, showed that more than two-thirds of California voters want behavioral health professionals to be part of the emergency response in non-life-threatening situations. Among seven types of situations potentially warranting emergency response, voters think law enforcement agencies are least equipped to respond to calls about mental health crises and people who are unhoused, according to the May 24 poll.
“Police response has become the oversized band-aid for something the band-aid was never designed to cover or heal,” said Ryan McClinton, who manages Public Health Advocates’ First Response Transformation Campaign.
His group and like-minded advocates in California are stepping up a campaign to overhaul the state’s 911 system so more mental health professionals and others with specialized training handle many emergencies, rather than the police.
Law enforcement officials agree that 911 response merits a more nuanced approach. But powerful police unions are against proposals that might reduce their control over 911 operations, and the budget and staff that go with them. Police representatives contacted said they favored alternatives that would supplement the current system rather than supplant it, and that would keep overall responsibility for 911 with police departments.
“Our 911 dispatchers do an amazing job and are the perfect people to handle those in crisis,” said Tim Davis, president of the Sacramento Police Officers Association, a union. “It is imperative that 911 remain under the direction of the police department, as the majority of the calls they receive are for police services.”
McClinton, however, said emergency response systems are outdated and in need of transformation. In many California counties, change is already underway. Forty-one of the state’s 58 counties have some form of mobile crisis services in which mental health workers go out and address crisis needs in the community, according to a survey conducted by the County Behavioral Health Directors Association of California.
Michelle Cabrera, executive director of CBHDA, said that by next year all California counties will have mobile crisis services up and running.
Established in 1968, 911 was designed for reporting fires. However, it quickly became an all-purpose system for routing a much broader set of calls to police.
Californians now make more than 25 million 911 calls annually. Nationally, as many as 15% are for behavioral health emergencies, according to a 2021 study in the journal Psychiatric Services.
Andrea Rivera, a legislative health advocate, said 911 centers today are inundated with calls that aren’t necessarily emergencies – an influx the system wasn’t built to handle.
“911 has become a catchall,” said Rivera, who works for the California Pan-Ethnic Health Network. “While it might be unfair to law enforcement, which doesn’t have the capacity or training, it’s particularly unfair for the community members that don’t feel like they have someone to turn to.”
Alternative approaches vary widely across the state. Santa Clara County, for example, has five mobile response teams that can respond to 911 calls, and can also be deployed by dispatchers at 988, the national Suicide & Crisis Lifeline.
Some teams are made up of clinicians and other trained professionals who can provide peer support. Some respond alongside police, while others arrive wearing plainclothes in a non-police vehicle.
Sandra Hernandez, a division director of Behavioral Health Services in Santa Clara County, said the program is in its infancy but has been effective so far. One surprising takeaway she noted was how much community members appreciated being able to ask for help without emergency vehicles arriving at their doorstep and alerting nosy neighbors to a moment of crisis.
Hernandez recalled one letter her team received from a grateful resident: “My neighbors didn’t even know. They thought I had company.”
Cities in Oregon, New Mexico and Colorado have similar programs.
Advocates point to cases like that of Jaime Naranjo, a Sacramento County resident who was shot and killed by police last year at his home. Naranjo’s wife, Elisa Naranjo, said her husband was suicidal and had been experiencing delusions and carrying a machete when she called 911 for help.
Sacramento has a Mobile Crisis Support Team, but it’s not 24/7 and Elisa called 911 outside its hours of operation. The Sacramento County Sheriff’s Office said that when police arrived the deputy told Naranjo to drop the weapon, but he did not comply. That, the Sheriff’s Office said, is when Naranjo advanced on the deputy, who shot and killed him.
In California, proposed legislation would make alternative response a statewide requirement. State Sen. Aisha Wahab’s SB 402, which is championed by Public Health Advocates, would require 911 service centersto dispatch professionals other than armed police officers for calls related to mental health or homelessness.
This approach is akin to the role 988 was meant to fill, Wahab said, but low awareness of the 988 number has been a barrier to effectiveness.
Wahab introduced an alternative response program three years ago in Hayward, while on its City Council, and said its success inspired her to draft the legislation. She said the bill, whose fate won’t be decided until next year, is a priority for her but acknowledged it would be complicated to enact changes statewide.
Police union representatives said they supported the idea of alternative response in principle.
“Our members are not mental health professionals,” said Alexa Pratt, the communications director for the Association of Orange County Deputy Sheriffs. “We agree that law enforcement should not be the lead addressing mental health calls but should be there to assist in these programs.”
Tom Saggau, a San Jose Police Officers’ Association spokesperson, referenced a pilot program in San Jose of which police were initially skeptical, until they saw how sharing the burden of emergency call response eased their workload. The program has grown sixfold in eight years.
Saggau, who also represents the Los Angeles Police Protective League, a union, said Los Angeles has drafted a list of 28 types of calls that could be diverted to other initial responders and don’t require a police presence.
Still, police departments are protective of their control over 911 and associated personnel and funding.
Saggau criticized proposals to restructure 911 as outgrowths of the “defund the police” movement and voiced frustration that some advocates think supporting alternative response requires a redistribution of police budgets.
The push to defund the police, which gained international momentum after George Floyd’s murder in 2020, refers to reallocating funding away from police departments to other government agencies that support social services.
“It’s not an either-or,” Saggau said. “You can have a fully staffed, robust police department and you can also have a robust alternative response model.”
Wahab believes it’s critical to ensure all cities and counties have clinicians and other unarmed emergency responders on hand.
“It’s very simple,” Wahab said. “You save lives by having the appropriate response to a crisis.”
