Crisis Intervention Team (CIT)

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Crisis Intervention Team (CIT)Methods for Using Data to Inform Practice:A Step-by-Step Guide

AcknowledgmentsThis report was prepared for the Substance Abuse and Mental Health Services Administration(SAMHSA) under SAMHSA IDIQ Prime Contract #HHSS283200700029I/Task OrderHHSS2834002T with SAMHSA, U.S. Department of Health and Human Services (HHS). StaceyLee served as the Government Contracting Officer Representative.DisclaimerThe views, opinions, and content of this publication are those of the authors and do not necessarilyreflect the views, opinions, or policies of SAMHSA or HHS.Public Domain NoticeAll material appearing in this report is in the public domain and may be reproduced or copiedwithout permission from SAMHSA. Citation of the source is appreciated. However, this publicationmay not be reproduced or distributed for a fee without the specific, written authorization of theOffice of Communications, SAMHSA, HHS.Recommended CitationSubstance Abuse and Mental Health Services Administration, Crisis Intervention Team (CIT)Methods for Using Data to Inform Practice: A Step-by-Step Guide. HHS Pub. No. SMA-18-5065.Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018.Electronic Access and Copies of PublicationThis publication may be downloaded at http://store.samhsa.gov/ or by calling SAMHSA at 1-877SAMHSA-7 (1-877-726-4727) (English and Español).Originating OfficeCenter for Mental Health Services, Substance Abuse and Mental Health Services Administration,5600 Fishers Lane, Rockville, MD 20857, HHS Publication No. SMA-18-5065. Printed in 2018.Nondiscrimination NoticeSAMHSA complies with applicable Federal civil rights laws and does not discriminate on the basisof race, color, national origin, age, disability, or sex. SAMHSA cumple con las leyes federales dederechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad.

Table of ContentsI.Introduction . 1Background . 1Data Collection and Program Measurement: Making the Most of Your Program Investment . 2Getting Started and Using this Report . 4II. Step-by-Step Guide: Creating a Local CIT Program Data Collection and Review Process . 5Step 1. Ensure the Right Partnerships are in Place . 5Foster alignment around agreed upon goals. . 5Increase data analysis in accordance with capacity. . 5Step 2. Document Your Local CIT Program. 6Outline the CIT program using maps, charts, or models. . 6Step 3. Identify Key Metrics . 9Determine what measures and data metrics are related to stated program goals. . 9Track measures and metrics most aligned with the CIT Model. . 9Organize data collection strategies based on community partners’ needs. . 10Step 4. Establish a Consistent, Routine Data Collection Process . 12Define a process, roles, and responsibilities for data collection and analysis. . 12Measure CIT program implementation. . 13Support regular, accurate data entry. . 14Develop useful dispatch and disposition codes. . 15Capture data about mental health calls in the dispatch system. . 16Codify program processes into policy. . 16Provide training on data collection procedures. . 17Step 5. Establish Regular Data Analysis and Reporting to the Field . 17Step 6. Incorporate What is Learned into Program Improvements . 18Identify areas for improvement. . 18Utilize existing resources to support evidence-based program improvements. . 19Step 7. Expand Program Data Collection as Capacity and Skills Grow . 20III. Recommended Data and Definitions . 21Tier One: Mission Critical Data . 21Community partnerships and engagement. . 21

CIT training participation. . 22Number of mental health calls for service/encounters. . 23Number of mental health calls responded to by CIT officers. 24Tier Two: Intermediate Data . 24CIT training outcomes. . 24Call disposition: healthcare referrals/arrest rates. 25Injury rate. . 26Use of force. . 26Tier Three: Advanced Data . 27Strength of partnership/ownership. 28Crisis response times and call duration. . 29Mental health call descriptors. . 29Treatment continuity. 31Impact on jail diversion. . 31Impact on recidivism rate. . 32Community engagement. . 32Changes in service utilization patterns across system partners. . 33IV. Conclusion . 35V. References . 36VI. Appendices . 39Appendix A. CIT Reporting Forms. 39Arlington County Police Department CIT Supplement Form . 39Central Florida CIT Tracking Form . 41Laurel Highlands Region CIT Data Sheet . 42Memphis CIT Center Statistics Sheet . 43Virginia Crisis Assessment Center Data Form . 45Appendix B. Data Entry Spreadsheet . 46Virginia Data Entry Spreadsheet and Data Definitions . 46Appendix C. Recommended Data At-a-Glance . 48Tier One: Mission Critical Data . 48Tier Two: Intermediate Data . 48

Tier Three: Advanced Data . 49Appendix D. Resources . 51Appendix E. CIT Training Evaluation Forms . 53Virginia CIT Pre-Training Assessment . 53Virginia CIT Post-Training Assessment. 55VII. Contributors . 58Key Informants . 58

I.IntroductionBackgroundThe Crisis Intervention Team (CIT) program has become a globally recognized model for safelyand effectively assisting people with mental and substance use disorders who experience crisesin the community. The CIT Model promotes strong community partnerships among lawenforcement, behavioral health providers, people with mental and substance use disorders, alongwith their families and others. While law enforcement agencies have a central role in programdevelopment and ongoing operations, a continuum of crisis services available to citizens prior topolice involvement is part of the model. These other community services (e.g., mobile crisisteams, crisis phone lines) are essential for avoiding criminal justice system involvement for thosewith behavioral health challenges – a goal of CITCIT Core Elementsprograms (Steadman & Morrissette, 2016). CIT isOngoing Elementsjust one part of a robust continuum of behavioral1. Partnershipshealth services for the whole community.2. Community OwnershipThe need for CIT programs is urgent and ever3. Policies & Proceduresapparent, as communities are challenged withOperational Elementsinsufficient mental health funding and services, yearsafter the de-institutionalization of people from state1. CIT: Officer, Dispatcher,Coordinatorpsychiatric hospitals. These communities now rely2. Curriculum: CIT Trainingheavily on law enforcement officers to provideassistance to people in crisis. As a result, people with3. Mental Health Receiving Facilitymental illnesses are more likely than the generalSustaining Elementspublic to experience arrest and to be injured or killed1. Evaluation & Researchduring encounters with law enforcement. The arrest2. In-Service Trainingrate for recipients of public mental health services is3. Recognition & Honorsestimated to be 4.5 times that of the general public4. Outreach(Fisher et al., 2011). While national data on policeFigure 1. CIT Core Elementsinvolved shootings is not systematically tracked,recent reports by the Washington Post (Lowery et al.,2015) and the Treatment Advocacy Center (Fuller et al., 2015) estimate that at least one in fourpeople fatally shot by police in the United States had a serious mental illness.The first CIT program was established in Memphis, Tenn., in 1988. The model created there hasproven to be replicable across jurisdictions and there is growing research evidence supporting itseffectiveness (Compton et al., 2014a; Compton et al., 2014b; Watson & Fulambarker, 2012;Watson, Morabito, Draine, & Ottati, 2008.). The “Memphis Model,” as it is often referred to, isconsidered the “gold standard” for effective CIT programming and can be considered evidencebased for improving several important outcomes (Watson, Compton & Draine, 2017). Based onCrisis Intervention Team (CIT) Methods for Using Data to Inform Practice:A Step-by-Step Guide, 20181

this model, the Crisis Intervention Team Core Elements report was created as a guidingdocument for programs in setting up and sustaining effective programming (Dupont, Cochran, &Pillsbury, 2007). The recommended processes for data collection and analysis provided in thefollowing sections are intended to complement the CIT Core Elements and provide support asprograms strive to develop the CIT program that works best for their community.1The CIT Core Elements are divided into three sections: Ongoing Elements, OperationalElements, and Sustaining Elements (see Figure 1). “Evaluation and Research” is listed as aSustaining Element and is a foundational component of an effective CIT program. Datacollection and analysis can be challenging due to constraints with technology, personnel, time,and other issues. However, these challenges are surmountable, and when armed with the rightdata, many programs are better able to show their impact and solidify the role of CIT insupporting law enforcement and improving responses to people with mental and substance usedisorders. The Ongoing, Operational, and Sustaining Elements of the CIT Model all offermeaningful data points and measures for CIT programs to consider tracking to help them meettheir short- and long-term outcomes goals.Data Collection and Program Measurement: Making the Mostof Your Program InvestmentWhile the Core Element of Evaluation and Research is often challenging for local CIT programs,it provides tremendous support to the other Core Elements of effective CIT programming: Document program activities: Collecting data to document program activities isimportant to understanding if the CIT program is being implemented as planned and canhelp identify gaps and problems with implementation. Additionally, as CIT programleaders examine outcomes data, having good documentation of the program will assist inunderstanding desired as well as unexpected outcomes and, where indicated, makingprogram improvements. Finally, good data on program activities is necessary toaccurately calculate costs of existing programs and estimating costs of programmodifications or expansions. Design program improvements: Data can help program stakeholders identify and targetimprovements to the program design and structure to achieve better outcomes. Forexample, findings may highlight or emphasize areas for improvement with theCurriculum or CIT Training (Operational Element 2), within the process of identifyingCIT calls and assigning them to CIT officers (Ongoing Element 3 and OperationalElement 1), or in the handoff policies and procedures at local designated mental healthreceiving facilities (Ongoing Element 3 and Operational Element 3).1The Crisis Intervention Team Core Elements can be accessed through the University of Memphis CIT Center athttp://cit.memphis.edu/pdf/CoreElements.pdf and CIT International at www.citinternational.org.Crisis Intervention Team (CIT) Methods for Using Data to Inform Practice:A Step-by-Step Guide, 20182

Demonstrate program effectiveness: Through meaningful data collection and analysis,CIT program leaders may better understand the program’s results and outcomes. Datacollected from officers participating in CIT training can demonstrate the impact onofficers’ knowledge, attitudes, skills, and satisfaction. Call data can be used to examinethe impact of CIT on safety outcomes, such as use of force and injuries, as well asdiversion and mental health service linkage outcomes. Over time, data from partneragencies can be used to examine changes in criminal justice system involvement ofpeople with serious mental illnesses and use of non-law enforcement crisis mental healthservices (e.g., crisis and warm lines, mobile crisis teams, triage centers). Ensure program sustainability: Data can help build a program’s identity and internalsupport from both executive and rank-and-file law enforcement officers by validating theprogram’s value and successes. Data collection and analysis can help persuade existingPartnerships (Ongoing Element 1) to continue supporting CIT and increase the resourcesallocated to sustain the program by producing numbers and findings that underscore thecollective impact of their efforts. Community Ownership (Ongoing Element 2) can alsobe fostered as people with mental illness, their families, and advocates better understandtheir role in helping achieve optimal outcomes for people with mental and substance usedisorder. Maximize utilization of scarce resources: Data can help ensure that CIT programs focustheir time and money on efforts that are most relevant to their communities. Anecdotalinformation, media hype, and other factors may draw attention to the many issues thatlaw enforcement and partners need to address; however, once informed by data, CITstakeholders can gain the confidence of community leadership that scarce fiscal resourcesand the time of CIT officers is properly invested. Data collection can also confirm toleaders that mental health is a critical issue impacting the local criminal justice system. Enhance officer and other frontline partners’ morale: When CIT programs provideofficers and frontline partners with information about the outcomes of CIT cases, theymay have a greater sense of empowerment helping people they believe need services.Sharing the information with officers and program partners may also build support for theprogram. Support the development of other community-based resources: As CIT programs gatherdata around the interactions between people with mental and substance use disorders andCIT partners, findings can be generated to support development of other neededcommunity-based behavioral health treatment programs and services. This will helpcommunities develop programs or expand services that assist citizens in distress avoidcontact with law enforcement and strengthen the overall continuum of behavioral healthservices. It also helps answer the question of what types of services are most appropriateto divert a person to.Crisis Intervention Team (CIT) Methods for Using Data to Inform Practice:A Step-by-Step Guide, 20183

Getting Started and Using this ReportIt is important for CIT partnerships to start to expand their data collection efforts in a way thatmakes sense for their local program. The CIT Core Elements report provides an ideal startingplace to identify what data to collect and analyze. Programs will first need to consider if they arecurrently collecting data that can be used to evaluate their program or if they will need to designnew strategies to capture the data needed. The step-by-step guide in Section II of this report willhelp programs create a system to ensure they have the necessary components in place for aneffective data collection and review process. Steps one through seven will walk programsthrough the foundational activities for identifying needed data and strategies to capture that data.These steps are based on the input, lessons learned, and successes of CIT programs across theUnited States.Section III of this report provides a breakdown of recommended data points, measurements, andmetrics for CIT programs to collect, broken out by three tiers: Tier One: Mission Critical Data Tier Two: Intermediate Data Tier Three: Advanced DataThis section aims to provide CIT programs across the nation with a consistent set of datadescriptions and definitions to standardize the way CIT programs gather, analyze, and talk aboutdata. By providing a uniform set of data descriptions and definitions, CIT programs may bettercompare their data and progress against that of other programs. The tiered approach helpsorganize and prioritize data collection efforts for programs that may otherwise be overwhelmedwith the volume and variety of potentially useful data to collect. Section III should be helpful asCIT partnerships work through the step-by-step guide, particularly at Step 3: Identify KeyMetrics and Step 7: Expand Program Data Collection.Crisis Intervention Team (CIT) Methods for Using Data to Inform Practice:A Step-by-Step Guide, 20184

II. Step-by-Step Guide: Creating a Local CITProgram Data Collection and ReviewProcessStep 1. Ensure the Right Partnerships are in PlaceThe CIT Model considers partnerships to be a Core Element in effective CIT programming.Partnership is also a critical aspect of data collection. Through these partnerships, the CITprogram should articulate the features of their program and establish goals or describe theanticipated result of implementing a CIT program inResearch Partner Opportunitiestheir community. (See Figure 2 for potential partners.)Foster alignment around agreed upon goalsThere should be alignment among partners so datagathered and analyzed are parallel with the goals andoutcomes sought by the CIT partnership. It isparticularly critical within law enforcement agencies tohave top leadership in agreement with the programgoals and the corresponding data collection and analysisefforts. The established partnership should work todevelop a vision for data collection, but as differentparties involved may have different priorities andinterests, compromise and planning will be necessary.Increase data analysis in accordance withcapacityProgram partners should work together to establishagreement to ensure plans for data collection arefeasible and produce good quality data. As programcapacity grows, data collection and analysis activitiescan expand.Local universities can often provide awealth of information and resources fordeveloping or expanding local CIT datacollection.Criminal justice, public health, socialwork, engineering, and informationtechnology departments can potentiallyprovide staffing through student andprofessorial support and expertise to helpwith: Developing logic models. Generating process flow charts. Creating electronic datacollection templates anddatabases. Providing data analytics support. Supporting dissemination of CITprogram information andsuccesses.Figure 2. Research PartnersPrograms having multiple partners with the capacityto perform data-related activities are encouraged to leverage this capacity and collect and analyzedata across partners. Step 7 will provide more guidance around this.Crisis Intervention Team (CIT) Methods for Using Data to Inform Practice:A Step-by-Step Guide, 20185

Step 2. Document Your Local CIT ProgramOutline the CIT program using maps, charts, or modelsSometimes, CIT programs will begin data collection before establishing a clear connectionbetween the data and the program’s goals, objectives, or activities. In these situations, they mayfind they are missing important data elements and the data they have collected is not as useful asthey had hoped. To avoid this, it can be extremely useful to gather partners to map out anddocument the program’s processes. This can be done by creating process maps, flow charts, orlogic models that connect the CIT activities to the eventual outcomes and goals of the CITpartnership. By writing and mapping the program processes, the data points and data sourcesthat are most needed for collection will begin to emerge. This process will help identify datapoints that are necessary for documenting implementation activities as well as outcomes.Including stakeholders and partners in this process will ensure important data points and sourcesare not overlooked and create buy-in for the data collection process itself. This improves thelikelihood that partners will work to collect and share the data needed to evaluate the program.Figure 3 provides one example of a CIT program logic model. A logic model is a useful tool forconceptualizing a CIT program and its specific resources (inputs), activities and participants(outputs) and intended results (outcomes). Many of the items listed as inputs and outputs maponto the CIT Core Elements. Not only does the logic model provide a roadmap of the programcomponents and how they are believed to work, it also identifies important elements to track andmeasure. While programs may not have the initial capacity to measure all elements, the logicmodel provides a guide to begin identifying data points that can be collected and analyzed.Crisis Intervention Team (CIT) Methods for Using Data to Inform Practice:A Step-by-Step Guide, 20186

INPUTSPartners:- Systems- Community- CIT coordinator- Police/agencytrainers- EvaluatorTraining items:-Training space- Materials/curricula- Backfill:Resources tocover the shiftsof officers/otherswhile they attendtrainingHavingdesignated dropoff site(s)identifiedOUTPUTSCollaboration:- Partner/stakeholdermeetings- Policy &procedure review- Recognition andawards- Outreach toothercommunitiesTraining:- 40-hour CITtraining- Advanced &refresher training- Partner trainingParticipation:- CIT coordinator- Law enforcementpersonnel- Emergencycommunicationspersonnel- Mental healthproviders- System partners- Communitypartners- People in crisis- FamiliesHYPOTHESIZED OUTCOMES*Short-termIntermediateLong-termterm : : :- Relationships- Knowledge,attitudes, skills- Linkage- Diversion- Problemsolving- Continuity ofcare- Engagement inservices- Nonemergencymental healthserviceutilization- Mental healthcrisis responsesystem change :- Use of force- Injuries- Arrests :- Jail population- Costs for lawenforcement,jails, healthcaresystem :- Repeat calls forserviceCIT response*Assumption: Implementing a CIT program will lead to better immediate response to mental health crisis calls (safety,linkage, diversion) and better service coordination and outcomes over time. Outcomes are hypothesized until measured.Arrows indicate the hypothesized direction of change.Figure 3. Example CIT Program Logic ModelProcess maps can also be useful. Figure 4 provides a process map of a CIT call process. Thisexample is intended to inspire ideas of how process mapping could be helpful to CIT programsjust starting or seeking to expand their data collection process. For example, Figure 4 makesclear the various dispositions (key outcome data points to gather) that may result from a CITprogram, as well as the partners involved with each disposition (who may need to provide thatdata).Crisis Intervention Team (CIT) Methods for Using Data to Inform Practice:A Step-by-Step Guide, 20187

Mental Health Crisis Call PathResolve onSceneVoluntaryPerson onInvoluntaryCIT Y/NTransport toTreatment:EmergencyDepartmentTriage CenterArrest/JailFigure 4. CIT Call Process MapWhile some jurisdictions may choose to work with a university partner or consultant to developlogic models and process maps, programs with limited capacity should not be deterred. Simplewritten descriptions, process maps, decision trees, and basic logic models can be created toclearly show the program components and desired results. Taking this step will help programsavoid overlooking important data elements and data sources and wasting valuable time andresources.2Having clarity about CIT processes is also helpful in continuing conversations among partners asneed for changes requiring substantial investments of time and resources emerge, such asupdating or replacing electronic databases, implementing more paperwork, or instituting otherchanges in how staff conduct their day-to-day work. With processes and anticipated resultsclearly documented, CIT programs can help keep stakeholders focused and support a consistentmessage about the purpose and function of the CIT program.2Cross et al., 2014, provides a conceptual framework of the CIT Model, which includes many of the outcomes thatleaders generally expect from their CIT programs. The basic logic model provided in the article is another examplethat can be used as a template and modified to reflect local CIT activities, results, and outcomes.Crisis Intervention Team (CIT) Methods for Using Data to Inform Practice:A Step-by-Step Guide, 20188

Step 3. Identify Key MetricsOne of the biggest challenges setting up a data collection process is deciding, “What is the datawe most need to support our local CIT program?” There are many items that can be tracked andpriorities will differ based on who is collecting and looking at the data. A foundational tenet ofCIT is the partnership between law enforcement and behavioral health organizations; however,there may be differing purposes for data collection due to the diverse perspectives andorganizational goals of the partners. All CIT programs will be in different places in terms ofcapacity and readiness to gather and analyze data.Determine what measures and data metrics are related to stated program goalsThe key to starting and sustaining an effective data collection process is to clearly understand thereasons for the CIT program, the activities being implemented, and the results sought. The CITCore E

Crisis Intervention Team (CIT) Methods for Using Data to Inform Practice: A Step-by-Step Guide, 2018 1 I. Introduction Background The Crisis Intervention Team (CIT) program has become a globally recognized model for safely and effectively assisting people with mental and substance use disorders who experience crises in the community.

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