Access Crisis Intervention (ACI) Programs

PURPOSE: This rule sets forth standards and regulations for ACI Programs. (1) The ACI program is provided or arranged by administrative agents. (2) The terms defined in section 630.005, RSMo are used in this rule. (3) Unless the context clearly requires otherwise, the following terms as used in this rule shall mean— (A) Access Crisis Intervention (ACI)—crisis intervention/ referral services provided twenty-four (24) hours per day, seven (7) days per week by telephone hotline or face-to-face mobile response at the location of the crisis or at another location in the community; (B) Administrative agent—an agency and its approved designee(s) authorized by the Division of Behavioral Health (DBH) as an entry and exit point into the state mental health service delivery system for a geographic service area defined by the department; (C) Advocate—individual who assists those receiving department-funded services with treatment planning, care issues, and the complaint/grievance and resolution process; (D) Community outreach/education plan—a plan outlining how individuals receiving services and their family members/ natural supports, advocates, state agencies, law enforcement and others in the community will become familiar with the local Access Crisis Intervention System; (E) Community Psychiatric Rehabilitation Program—a specialized program that provides or arranges for, at a minimum, the following core services: eligibility determination, initial comprehensive assessment, annual assessment, treatment planning, crisis intervention and resolution, medication services, physician/professional consultation services, medication administration, community support, metabolic syndrome screening (for individuals receiving antipsychotic medication), and psychosocial rehabilitation in a nonresidential setting for individuals with serious mental illness or serious emotional disturbances; (F) Community support—as defined in 9 CSR 30-4.047; (G) Crisis Intervention Team (CIT)—law enforcement officers with specialized training for response to behavioral health crisis; (H) Individual served—anyone receiving department-funded services directly from an organization/agency; (I) Internal agency protocol—a specific method indicating how the agency plans to respond to guidelines set forth by the department; (J) Mobile crisis response—specialized staff available twentyfour (24) hours per day, seven (7) days per week to assess and intervene face-to-face with individuals where the crisis is occurring or another secure location in the community; (K) Qualified Mental Health Professional (QMHP)—as defined in 9 CSR 10-7.140; (L) Risk assessment—the process of assessing dangerousness to self or others; (M) Residential crisis services—a service used for persons who are at high risk for hospitalization or who are being diverted from hospitalization and can include specific crisis stabilization units, group homes, residential, apartments, motels/hotels, and foster home type settings; (N) Specialized program—programs operated by an agency that provide specific services to designated eligible individuals enrolled in that program; (O) Telephone hotline services—a published, centralized, twenty-four (24) hours per day, seven (7) days per week staffed toll-free telephone number to provide direct means of crisis assessment and triage for individuals in crisis, their families/ natural supports, and agencies needing assistance; and (P) Withdrawal management/detoxification—support provided to persons served during withdrawal from alcohol and/or other drugs. (4) Records and Documentation Requirements. (A) A treatment plan is not required for individuals receiving only telephone hotline or mobile outreach through the ACI program. Evidence of coordination between the ACI staff and the treating staff for individuals currently receiving department-funded services, or those who are in the process of being admitted to a CPR program, must be documented in the individual record. (B) At a minimum, programs funded for ACI must keep the following records for telephone hotline services when possible to obtain from caller: 1. Date and time of telephone call; 2. Identity of caller, including but not limited to, parent, individual receiving services, law enforcement, judge, hospital, emergency room, mental health professional; 3. Name, address, telephone number, and date of birth; 4. Presenting problem; and 5. Disposition and follow-up. (C) ACI programs must have a method for retaining hotline data in compliance with 9 CSR 10-7.030. (D) When a call is received on behalf of another individual who is in crisis, the caller and the individual in crisis must both be identified as recipients of the crisis intervention services provided by the ACI program. For data collection purposes, the identified service recipient is the individual in crisis. (E) At a minimum, agencies providing ACI services must keep the following records for mobile outreach services when the individual agrees to provide identifying information: 1. Date and time of referral; 2. Date, time and place of face-to-face contact; 3. Person accompanying mobile worker; 4. Person in attendance at face-to-face contact; 5. Name, address, telephone number, date of birth; 6. Presenting problem; and 7. Disposition and follow-up. (F) The agency must document when the individual does not provide identifying information. (G) Agencies providing ACI services must submit data reports and documentation to the department in accordance with the department’s standardized form and protocol. (H) Agencies providing ACI services must meet the documentation and confidentiality requirements as defined in (5) Treatment. (A) Each administrative agent must provide or arrange for the delivery of ACI services. (B) ACI programs must operate or arrange for a twenty-four- (24-) hour per day, seven (7) day per week telephone hotline. Each program shall have a written description of the telephone hotline system including the following: 1. Name of the agency or contractor that operates the hotline; 2. Numbers and qualifications of hotline staff; 3. Written documentation that clinical supervision is provided including, but not limited to: meeting minutes, supervision logs, or peer review processes; 4. Written description of how the telephone hotline is staffed; 5. Written documentation of case reviews and quality assurance activities relating to hotline services; 6. Written documentation of how telephone hotline services are provided to individuals who are deaf, have limited English proficiency, or are from cultural minority groups; 7. Written description of ongoing hotline outreach activities; and 8. Written description of a process for identifying and utilizing community resources in the delivery of telephone hotline service. (C) Each administrative agent must have a designated agency staff person or persons on call to the ACI system twenty-four (24) hours per day, seven (7) days per week. (D) If the individual served, advocate, family member/ natural support requests to speak with a staff member from a specialized program including, but not limited to, the CPR program’s community support specialist and the ACI clinical staff have determined this action is clinically necessary, the ACI hotline staff shall contact the appropriate designated agency staff person. (E) The ACI hotline staff shall remain in contact with the caller until a successful hand-off contact between caller and designated agency staff person has occurred. (F) Once contact between the caller and agency staff has occurred, the designated agency staff person shall respond to the caller and/or secure the appropriate requested specialized program personnel involved. (G) The designated agency staff person shall remain in contact with the caller until a successful hand-off or contact between specialized program personnel and caller has occurred. (H) Each administrative agent must have a written internal agency protocol in place for how the designated agency staff person will be able to contact staff from specialized programs that require twenty-four (24) hour, seven (7) day per week crisis intervention as a component of their service menu. (I) If ACI staff does not follow the procedure listed in subsection (H) of this rule, there must be a written protocol for contacting the ACI supervisor and the specialized program supervisor within twenty-four (24) hours to review the immediate action taken and then reviewed for a performance improvement process within forty-eight (48) hours. (J) ACI programs must have a written description for resource and referral to the following services: 1. Acute hospitalization; 2. Medical services; 3. Withdrawal management/detoxification services; 4. Priority outpatient scheduling within twenty-four (24) hours or the next working day; 5. Children and youth services; and 6. Psychiatric availability. (K) ACI programs must operate a twenty-four- (24-) hour per day, seven (7) day per week mobile response system. Each program shall have a written description of the mobile response system including the following: 1. Name of the agency or contractor that operates the mobile response system; 2. Written description of how mobile crisis response teams are staffed twenty-four (24) hours per day, seven (7) days per week; 3. Numbers and qualifications of staff; 4. Written documentation that clinical supervision is provided including, but not limited to: meeting minutes, supervision logs, or peer review processes; 5. Written documentation of case reviews and quality assurance activities relating to mobile response services; and 6. Written documentation of how mobile response services respond to individuals who are deaf, have limited English proficiency, or are from cultural minority groups. (L) ACI programs shall provide mobile response to known and unknown individuals twenty-four (24) hours per day, seven (7) days per week at the location of the crisis or another secure community location. (M) Mobile response shall not be provided exclusively in emergency rooms, jails, or mental health facilities. (N) When a call is referred to mobile response, a phone-only response is appropriate if the clinical needs of the person who is in crisis can be addressed over the phone and/or the crisis has been deescalated. (O) Each agency providing ACI services must have safety mechanisms in place for mobile response. These may include, but are not limited to: 1. Mobile phones; 2. Risk assessments for phone and continually during contact; 3. Availability of multiple staff to respond for face-to-face contact; 4. Backup availability; and 5. Written protocols for mobile response to be delivered in safe locations when necessary. (P) In crisis situations in which law enforcement need to be contacted by the ACI staff, the ACI staff must make the initial contact and remain involved until the crisis is resolved, by phone or with the mobile response team. 1. ACI staff shall first contact law enforcement officers trained in crisis intervention, if they are available in the city/ county where the crisis situation is taking place and ACI staff have established arrangements to make direct contact with them. (Q) If the caller is not satisfied, the grievance procedure must be followed as defined in 9 CSR 10-7.020(7). (6) Performance Improvement. (A) Each administrative agent must develop a community outreach/education plan that includes details of how the following groups will become familiar with the ACI system: 1. Families/natural supports; 2. Individuals receiving services; 3. Advocates of individuals receiving services; 4. State agencies including, but not limited to, the Department of Social Services, Family Support Division, Children’s Division, and Division of Youth Services; the Department of Health and Senior Services, Division of Senior and Disability Services; and the Department of Corrections, Division of Probation and Parole; 5. Emergency responders (law enforcement agencies, 911, paramedics); 6. Primary and secondary schools; 7. Court system including, but not limited to, juvenile, family, mental health, and drug courts; 8. Residential care programs, homeless shelters, public housing; 9. Public health agencies; 10. Community health centers; 11. Primary care medical offices; and 12. General public. (B) The community outreach/education plan must include the various action steps that will be taken in educating the community as to how to access the ACI system through written material and other means of communication. (C) The community outreach/education plan must indicate how the components will be accomplished on an ongoing basis. (D) Agencies providing ACI services must be able to demonstrate their community awareness and education activities, at least annually, in a report or other format specified by the department which may include, but is not limited to, number of hotline calls, walk-ins, media outreach, and outreach/educational efforts with schools, law enforcement, or other entities in the community. (E) The telephone number for ACI must be published in local telephone books distributed in each service area and be prominently displayed on agency websites and social media pages. (F) If the level of crisis services provided by an agency is significantly below the state average or other established benchmarks, this circumstance must be addressed in the performance improvement plan. (G) Agencies providing ACI services must promptly respond to requests from local institutions of higher education to assist in developing appropriate crisis response systems on college campuses. (7) Personnel and Staff Development. (A) Staff providing telephone hotline services must have a bachelor’s degree with three (3) years of behavioral health and crisis intervention experience or a master’s degree with one (1) year of behavioral health and crisis intervention experience. 1. Staff providing telephone hotline services must be supervised by a QMHP. 2. Staff providing telephone hotline services must have immediate access to a QMHP. (B) For mobile response, the mobile crisis team shall have at least one (1) QMHP to provide face-to-face crisis intervention for each mobile response. (C) Each administrative agent shall designate a coordinator for ACI services who must be a QMHP. (D) The agency shall have written documentation that clinical supervision is provided on a scheduled basis including, but not limited to: meeting minutes, supervision logs, or peer review processes. (E) For administrative agents that subcontract for hotline services this standard applies. Administrative agents shall have designated staff on call to the ACI system twenty-four (24) hours per day, seven (7) days per week for specialized programs. This designated staff person or persons shall have received crisis intervention training and have experience in responding to crisis situations with individuals and families. (F) Each agency shall have an ACI Training Plan. The training plan shall include individuals served, families/natural supports, and advocates in the development and implementation of the plan. (G) Staff providing ACI services shall complete the designated ACI training required by the department at least annually that includes, but is not limited to, the following core competencies as defined by the department: 1. Crisis intervention strategies and techniques; 2. ACI and legal issues; 3. Safety; 4. ACI responsiveness to individuals and families served; and 5. Available resources and services in the community. (H) ACI staff shall have a working familiarity with the core competencies prior to providing crisis intervention services. (I) New ACI staff shall be trained and document the demonstration of the core competencies within the first six (6) months of employment. (J) The administrative agent shall describe how the core competencies will be incorporated into the ACI staff training program on an ongoing basis. (K) Each agency shall provide a written plan of how it will measure the competencies of the ACI staff. The plan must include at least two (2) measurable outcomes including, but not limited to: 1. Review of case documentation; 2. Review of assessment forms for appropriate interventions; and 3. Question, answer, observation, and feedback by supervisory staff and peers. (L) New ACI staff must receive clinical supervision and jobshadow the supervisor or experienced crisis workers for a minimum of forty (40) hours prior to providing crisis services. AUTHORITY: sections 630.050 and 630.655, RSMo 2016.* Original rule filed Aug. 28, 2002, effective April 30, 2003. Amended: Filed Dec. 29, 2003, effective July 30, 2004. Amended: Filed April 29, 2019, effective Nov. 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980.