Building an Ideal Crisis Care System: The Role of Accountable Entities

Behavioral health systems providing crisis care, including those serving 988 callers, face intense pressure to meet the complex needs of at-risk individuals. And that pressure is only growing after the suicide hotline number change in July 2022, which has not only led to increased call volumes but also created more opportunities for people to easily reach out and receive services in their language or customized to their age or sexual identity. 

As a result, these systems need to ensure that each provider is coordinating seamlessly with all other stakeholders. But who is responsible?  

In its “Roadmap to the Ideal Crisis System,” the Group for the Advancement of Psychiatry says: “An ideal behavioral health crisis system must have a mechanism to both finance a comprehensive continuum of crisis services and ensure the accountability and quality of the continuum’s performance.” That “accountable entity” provides oversight for 988 and crisis management systems.

What is an accountable entity? 

Broadly speaking, an accountable entity holds the crisis management system accountable for meeting performance standards and community needs. As the authors write, “While no system will ever likely reach the ideal, the aspirational goal is, ‘Every person receives the right service in the right place, every time.’” 

To manage crisis care systems, different layers of government and various sectors must work together, regardless of which entity is accountable. The primary role of the accountable entity, according to the roadmap, is to ensure proper management and continuous improvement in the quality and outcomes of the services provided to the population, safeguarding the welfare and well-being of the people served by the system. 

Responsibilities include ensuring that: 

• Individual service rates and overall funding are adequate to cover the cost of the services 
• Mechanisms are in place for tracking customers, customer experience, and performance 
• Data is shared — including aggregate performance data and personal health information (PHI) — to improve performance 
• Quality standards are identified, formalized, measured, and continuously monitored 

There’s no single structure for accountable care entities. The report offered three vastly different examples: 

• In Arizona, Medicaid-managed care intermediaries function as accountable entities for crisis systems that serve everyone, not just the Medicaid population. 
• In Pennington County, S.D., a county-led collaboration of agencies and providers serves as the accountable entity, with the Sheriff’s Office holding ultimate accountability.  
• In Kent County, Mich., it’s a collaboration among the county, four health systems, three behavioral health organizations, and the entity that manages specialty behavioral health Medicaid and indigent services. 

Meeting the needs of all community members

The accountable entity designs and coordinates funding and services for a continuum that meets the needs of the entire community — providing services commensurate with population size and the geographic area served, and for all individuals, regardless of whether they’re insured.  

This requires coordination and connectivity. It is not adequate to simply have an array of discrete programs and providers. Everyone within the system must work collaboratively to ensure that the various components operate cohesively to serve all community members in a timely manner. Ideally, they’re working on a shared technology platform that supports collaboration, data sharing, and communications, and includes telehealth services for rural and frontier areas where on-site service is limited. 

Implementing values-based accountability 

The accountable entity must incorporate and maintain core organizational values across all processes, focusing on person- and family-driven values. That means they need to ensure welcoming, hopeful, safe, accessible, recovery-oriented, resiliency-enhancing, and trauma-informed care. The roadmap emphasizes the importance of eliminating disparities and supporting the vulnerable and marginalized. 

Accountability for these core values requires the systematic collection and review of feedback from consumers, families, providers, and other stakeholders. “It is essential to regularly address identified areas for improvement in the delivery of value-based services in systemic, continuous quality improvement activities,” the roadmap notes. 

The accountable entity must define specific quality metrics across various areas. This not only ensures that the crisis system meets the needs of those it serves, but it also provides transparency to funders and other stakeholders. After the suicide hotline number change to 988, the already large variety of metrics has increased, but they still fall into three basic categories: structure, process, and outcome.

The roadmap provided a few specific examples, including the percent of:  

• crisis customers who have welcoming, hopeful customer experience 
• crisis calls that are resolved without having to dispatch police
• individuals discharged safely to non-hospital settings
• families engaged collaboratively in the crisis intervention process 

Following client flow across the care journey

Another vital role for the accountable entity is to implement a system that can follow client-specific data through the crisis care journey, so stakeholders can understand patterns in the utilization of services and ensure that no clients fall through the cracks. This responsibility lies heavily on the shoulders of a strong crisis call center that monitors client flow, including the recording of all calls (with details of care delivery) and documented follow-up across the care continuum.  

A client monitoring data system has, at minimum: 

• A systemic level of care assessment, which uses formal definitions for levels of care available, tracks crisis origins, and identifies care required with a multidimensional assessment that includes comorbidities and social determinants of health 
• Resource identification, such as bed and transportation availability 
• Data system reporting through a single, easy-to-understand dashboard
• Prompt reporting of any crisis encounters, ER visits, and hospital admissions to the client’s most frequently seen behavioral health and primary care provider, for care coordination 

Monitoring throughput to deliver efficient service

Each element of the crisis management system must operate in concert to respond to variations in demand. Continuous monitoring is necessary to ensure that minor delays in one area don’t lead to larger, systemwide bottlenecks. “Processes must be in place to both respond in real time to fluctuations in demand and barriers to flow and periodically review whether the system has the adequate capacity and operational processes to meet community needs,” states the roadmap. 

This requires the accountable entity to create capacity through adequate funding and staffing, have response plans for changes in demand, and develop solutions for systemic barriers. They further must define quality metrics that reflect expectations for timely care and efficient flow, such as: 

• Time until the person seeking service gets what they need 
• Flow from one level of care to another 
• Indicators of excessive waits 

Pulling it all together with a single platform 

To effectively manage community needs, providers need a technology solution that keeps pace, ensuring each caller receives immediate and appropriate assistance, and that operational tasks and care coordination activities don’t get overlooked.  

988 and crisis care centers benefit when they consolidate their technology into one shared care management platform. A platform like Core’s Cx360 allows them to streamline real-time communications, appointment scheduling, and bed tracking, enabling faster and more informed decision making. Warm handoffs are easier, and anyone who touches a client can follow that person’s journey, including assessments, treatment plans, and progress notes. 
 
Moreover, by simplifying such tasks as billing and reporting, Cx360 frees crisis center teams to focus on their callers rather than paperwork. 
 
To learn more about how the platform works, reach out to schedule a demo.  
 
SCHEDULE A DEMO