MHW: Trauma Informed Alternative to Traumatic ER/Inpatient Use

NYAPRS Note: A recent study found that the use of peer staffed crisis respite programs reduced avoidable readmissions and Medicaid spending. The NYS Office of Mental Health has committed $50 million in capital funds to establish such programs across the state. The programs’ sustainability may well depend on both Medicaid and commercial health plan reimbursement. See more below.

 Peer-Staffed Crisis Respite Program Effective Alternative to Hospitalization

Mental Health Weekly August 13, 2018

 The implementation of peer-staffed crisis respite services to divert individuals from hospitalization can achieve savings in Medicaid expenditures and reduce reliance on hospital services, according to new research published online in Psychological Services in Advance.

 The study, “The Effectiveness of a Peer-Staffed Crisis Respite Program as an Alternative to Hospitalization,” examined whether peer-staffed crisis respite centers implemented in New York City in 2013 helped to reduce emergency department (ED) visits, hospitalization and Medicaid expenditures for Medicaid beneficiaries.

 The environment and services offered in peer-staffed crisis respites are distinct from ED and hospital care. Unlike locked units of hospitals, crisis respites offer a voluntary, safe and homelike environment where trained peer staff provide 24-hour support to individuals experiencing psychiatric crises, researchers stated.

 “When people with serious mental illness have a crisis in their lives, often their only option for help is an emergency room or a hospital,” Jonathan Brown, Ph.D., director of health policy assessment and area director for behavioral health at Mathematica Policy Research, and co-author, told MHW.

 He explained that some new programs offer another option that can provide a safe, home-like environment with staff who know how to provide care because they have been down the same road in the past. “We refer to these programs as peer-staffed crisis respite centers, and our study examined whether they work,” Brown said. “Specifically, we wanted to know whether having this option available led to fewer emergency room visits, and hospitalizations and lower costs.”

 Researchers noted that, overall, there is limited evidence on the potential for peer-staffed crisis respites to reduce hospitalizations and lower the overall costs of health care. The current study, they note, fills this gap in the literature. “What is different about this study is that we used a more scientifically rigorous approach, which means that readers can have more confidence that the answers to our questions are accurate,” Brown stated.

 He added, “Specifically, our study used a rigorous comparison group design to determine if receiving peer-staffed crisis respite services had an impact on the utilization of other Medicaid services and total costs of care.”

 Study Methods

Researchers examined a peer-staffed crisis respite program implemented in New York City through the Parachute NYC program, which introduced the use of peer specialists to New York City’s mental health crisis program. The goal of the program was to improve the quality of care provided to individuals in need of crisis mental health treatment while reducing Medicaid expenditures through reductions in hospitalizations and ED visits.

 In the respite centers, peer staff provide individuals in crisis with education in self-advocacy and self-help, and other services.

 Between January 2013 and March 2014, Parachute NYC gradually opened four respites, one in each borough except Staten Island (see profile of one of the first programs on opposite page). 

 Crisis respites were generally staffed by 20 to 30 peers, were supervised by three to five non peers and served approximately five to 20 participants per month. A nurse was on-site periodically to ensure that the guests’ clinical treatment needs were met. All crisis respite staff members received training in the need-adapted treatment model and intentional peer support.

 “Intentional peer support is a trauma-informed approach that integrates peers into treatment and focuses on building relationships between clients and peers,” Brown explained, adding that a nurse was also present at the centers to help clients with medical screening, referral and education. Clients come and go from the crisis centers, which allows them to maintain relationships, jobs, child care and other activities, he said. Clients and members of the support network are full participants in treatment decision-making.


In the month of crisis respite use and the 11 subsequent months, Medicaid expenditures were, on average, $2,128 lower per Medicaid-enrolled month.

 Additionally, there were 29 fewer hospitalizations for crisis respite clients than would have been expected in the absence of the intervention, researchers stated.

 Researchers acknowledge that although they cannot fully explain the mechanism by which the crisis respite program achieved reductions in hospitalizations and Medicaid expenditures, certain features of the program — such as targeting patients in need of hospital care, use of intentional peer support, and the training and supervision of peer staff by experts in this model — may have contributed to its success.

 “The promising findings from this study may encourage state Medicaid programs to consider this model as an alternative to hospitalization for individuals experiencing a psychiatric crisis,” Brown said. Although most state Medicaid programs cover some type of peer support services, state Medicaid programs vary considerably in the generosity of their peer support benefits, reimbursement rates and the Medicaid populations eligible for peer services, he said.

 Brown added, “A state would need to ensure that their Medicaid benefits adequately support the implementation of peer-staffed crisis respite services, and that Medicaid beneficiaries who would benefit from the services are eligible.”

 “We hope this cost-saving analysis incentivizes payers, public and private, and drives the whole insurance marketplace to pay for peer respite [services] as an alternative to inpatient psychiatric hospitalization,” Jamie Neckles, chief program officer in the Bureau of Mental Health of the New York Department of Health and Mental Hygiene, told MHW.

 Inpatient psychiatric hospitalization can be traumatic and restrictive, she said. Respite services allow individuals to get 24/7 support during a mental health crisis, Neckles noted.

 Researchers stated that because crisis respite centers are dependent on referrals, they benefit from strong relationships with a variety of providers in the community. The respite centers they examined received referrals from crisis hotlines, mobile crisis teams, hospital emergency departments, primary care providers and other community-based organizations.

 It’s important that other mental health providers know about the respite centers and about the evidence that they can have positive effects for people with serious mental health problems, researchers wrote, concluding that peer-staffed crisis respite services can achieve system-level impacts.

 Respite Homes Increasing

Peer-staffed crisis respite homes are popping up not just across the state, but around the country as well, Harvey Rosenthal, executive director of the New York Association of Psychiatric Rehabilitation Services, told MHW.

 “Over the last five years, their use has really exploded,” said Rosenthal. “It’s not only because the approach makes a lot of sense — it’s very cost-effective.”

 Rosenthal added, “When you get the right response in a crisis, you get back on track and are far less likely to be recommitted. It’s a win for everybody — consumers, families, providers and payers.”

 Rosenthal noted that the New York State Office of Mental Health successfully advocated for a $50 million capital investment to grow programs of this kind across the state in the coming years.

 The state’s Medicaid managed care, although currently going through reform in the state, could become the biggest payer and an investor in this program, he said. Funding going forward still remains an issue, he said.

 “This research makes it clear we need to have these programs in almost every community,” Rosenthal said.

New York City Respite Center Helps People in Crisis with Comforts Of Home

One of New York City’s first respite centers staffed entirely by peers is nestled in a building on Second Avenue in Manhattan. The alternative to hospitalization represents a place consumers or “guests” can go when they’re experiencing a mental health crisis.

 “The program has been in operation for more than five years with an average of 40 guests per month,” Steve Coe, CEO of Community Access, a New York City–based nonprofit agency that runs the program, told MHW. 

 The home includes 14 beds and the average length of stay is about seven days, he said. “We have been able to interact with people in a whole different way,” Coe said.

 Instead of being isolated in a hospital, the guests get to dine with staff. They plan meals together and go shopping, he said.

 “We help people talk about what kind of strategy is needed to leave respite care and prevent the kind of crisis they had experienced,” he said. “There’s no service planning and no medication management. It’s more like a social gathering and a comfortable place for them.”

 Blending In

From the outside, the respite home looks like any other building in Manhattan, said Coe. “We receive lots of referrals from hospitals, therapists and clinical programs,” he said. About one-third of guest heard about the program from other people. Over the last five years, there’s been a 90 to 95 percent occupancy rate, he added.

 “What contributes to the program’s success is that people are not treated as though something is wrong with them,” Coe said. They’re treated well and they know the home is a safe place for them, he said.

 Sustainable funding for the program is always a concern, especially in an increasingly Medicaid managed care world, said Coe. The state is in the midst of Medicaid managed care reform. Currently, funding comes from a combination of grant contracts with the city (about 75 percent) and billing Medicaid (25 percent), he said.

“Over time, it’s expected insurance billing will go up and contract dollars will go down with Medicaid reform,” said Coe. Medicaid insurance companies are looking at opportunities to keep people out of hospitals, he said. “They will pay a decent rate to make that viable,” Coe said.