Alternatives to Police as First Responders: Crisis Response Programs

By Matt DeLaus^*

November 16, 2020

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Summary

For 911 calls about someone in crisis, who should respond? Many cities have decided it should not solely be police. A national poll conducted in June found that 70% of likely voters support a non-police response for 911 calls about mental health crises, and 68% support the creation of non-police emergency response programs.¹

In many jurisdictions, police are the first to respond (first responders) to 911 calls about people experiencing issues related to mental health, homelessness, and substance abuse. However, they often do not have adequate training to deal with these calls.²

Programs replacing police with social workers, mental health counselors, and medical staff have been in operation for at least a year in Austin, Texas; Eugene, Oregon; Olympia, Washington; and Edmonton, Canada. Eugene’s program has operated since 1989, and in 2019 responded to 20% (24,000) of all 911 calls, with a police backup request rate of 0.625% (160).³These programs are focused on providing more appropriate services and

reducing government spending. Other cities have recently begun or approved crisis response programs of their own.⁴

Potential benefits include budgetary savings, diverting individuals from a higher level of care, and reducing dependence on policing and the criminal justice system to deal with people experiencing crisis. There are also obstacles, as well as many questions about program design and implementation. Some considerations are universal, and some vary based on how each program is structured, as well as its size and scope.

Although the programs vary, takeaways for local governments attempting to implement a crisis response program are to (i) include stakeholders in the program design process,

(ii) aim to build trust within the police department and community, (iii) have a designated place within the 911 and emergency-response processes, (iv) have adequate funding with access to mid-year increases if necessary, (v) have a capable host organization/agency and be appropriately administratively housed, (vi) properly train employees, 911 call-takers, and other first responders, (vii) use past and current call data to inform operations, and (viii) have the ability to transfer or refer clients to other service providers.

Who Operates Crisis-Response Programs?

The organizations that operate crisis-response programs generally do so through a subcontract with the city or police department (with the exception of Edmonton’s program, which is run by a nonprofit).⁵

Eugene’s CAHOOTS is administered by White Bird Clinic,⁶an independent nonprofit which has provided community-based healthcare services (including mobile crisis response) since 1969, and is well known in the Eugene community.⁷Workers “are White Bird Clinic employees, contracting with the police department, and the county.”⁸

Austin’s EMCOT program is administered by the Travis County (which encompasses Austin) Local Behavioral Health Authority,⁹ called Integral Care, which is a community-based mental health center that has been providing behavioral health services for over five decades.¹⁰In addition to mobile call-response staff, some mental-health counselors are stationed at Austin’s 911 call center.¹¹Travis County EMS also oversees the Community Health Paramedics program, which targets frequent users of 911 and provides mobile case management, both medical and non-medical.¹²Workers are employed by the Travis County Healthcare District¹³through a contract with the city.¹⁴

Olympia’s Crisis Response Unit is administered by Recovery Innovations International, which is a mental health services provider from the neighboring county with “14 crisis programs in five states,” although it has no other alternative first response programs.¹⁵The Administrative Services Division of the Olympia Police Department handles the contract, because that division does not include sworn officers.¹⁶

Edmonton’s 24/7 Crisis Diversion program is administered by REACH, a “backbone” organization, or “community-based coordinating council” funded by the city.¹⁷ Program workers are employed by Boyle Street Community Services and Hope Mission (two local nonprofits that provide similar services in Edmonton), and the call- takers are employed by the Canadian Mental Health Association (211).¹⁸

What Kind of Services Do Alternative First Responders Provide?

They are voluntary, meaning people can refuse services and opt for a police or EMS response instead. Because they are mobile, they can engage clients directly without being dispatched, except for Austin’s EMCOT, which is dispatched by 911 or other first responders.¹⁹Currently, 911 calls about a person in crisis are generally responded to either by police officers trained in a forty-hour “Crisis Intervention Team” program, or by police officers with no training beyond the police academy.²⁰ Current mobile crisis response programs are run either at the county level or by a nonprofit organization; workers are not

dispatched after 911 calls but at the request of law enforcement on scene. The programs are generally underfunded.²¹People experiencing issues related to untreated mental illness are sixteen times more likely to die during encounters with police than other civilians.²²

Also, programs can either preempt other first responders from responding to a call, or allow other first responders to leave a scene when it is unnecessary for them to stay.²³ 911 call-takers in Eugene use the same channel to dispatch CAHOOTS and the police department, both of whom use the same radios. If a CAHOOTS worker has a relationship with the person being called about, they can communicate with the officer to either replace them as a responder or co-respond. Additionally, other first responders can call CAHOOTS workers to the scene of a call, and “leave the scene” with CAHOOTS workers. This saves time for those first responders to respond to other calls.

All programs can attend to non-emergency medical issues, although in Austin those are generally dealt with by the Community Health Paramedics.²⁴Workers in all of the programs also all have the ability to transfer or refer clients to appropriate services or agencies with the client’s consent.²⁵

CAHOOTS and EMCOT workers also teach methods of crisis management and conflict resolution to law enforcement and community members.²⁶

In Eugene, CAHOOTS workers respond to a variety of other non-emergency calls, and

provide services including, but not limited to:

• conflict resolution and mediation;
• dispute mediation and resolution between family members, roommates, or clients at group homes or agencies;
• delivering death notifications;
• welfare checks;
• grief and loss counseling;
• substance use and abuse counseling;
• providing water bottles, socks, and other basic supplies to people;
• addressing housing crises;
• first aid and non-emergency medical care;
• resource connection and referrals;
• providing direct funds for essential items;
• transportation to services, and
• situations in general that do not involve emergent medical or criminal issues.27

When other first responders notice someone in distress from a call (like someone who called about a home invasion), they can ask that person if they’d like CAHOOTS to come and help them process what they’re feeling.²⁸At least once, a CAHOOTS worker has de-escalated a situation by standing between an officer and a civilian to prevent the officer from using mace, but it is unclear if that is a common or accepted practice.²⁹CAHOOTS did not originally have the ability to do most of these things, but as it gained expertise and trust with the department and community, its functions expanded.³⁰

Appendices B and C are tables of available response data for 24/7 and CAHOOTS.

Connecting Clients to Other Service Providers and Programs

Organizations that host crisis-response programs are mostly local organizations that did similar work in their communities before they began administering their respective programs.³¹This helps them to connect clients to multiple agencies to provide sustainable support, especially for clients with more complex needs.³²Common partners include healthcare providers, hospitals, homeless shelters, homeless- outreach agencies, mental-health clinics, substance-abuse programs and clinics, and other emergency-services diversion programs. Austin’s EMCOT program works in tandem with Austin’s other nontraditional 911 program, the Community Health Paramedics.³³Olympia’s CRU program was funded by a 2017 public-safety levy approved by voters.³⁴That levy also paid for a program called Familiar Faces, which targets and assists frequent users of emergency services to better support them with long-term care.³⁵

Program Operations

Point of Access

The CAHOOTS program coordinator said their “biggest struggle” is figuring out how clients can access their services, and said it is the “key thing” for communities implementing a crisis response program.³⁶ The Eugene Chief of Police testified before the Oregon legislature that the most important aspect of the program was its ability to be dispatched by the 911 call center.³⁷

All programs can be called by other social service agencies.³⁸Only Edmonton’s 24/7 program is not able to be dispatched directly by 911 call centers.³⁹ CAHOOTS and EMCOT did not originally have that  ability,⁴⁰while Olympia’s Crisis Response Unit was integrated into the 911 process from its beginning.⁴¹Austin’s original crisis response program, MCOT, is available at a standalone phone number housed at Integral Care’s clinic, while EMCOT is available to 911 dispatchers, EMS, and law enforcement.⁴²Austin 911 dispatchers are now trained to ask whether the caller needs police, fire, or mental health services.⁴³In Olympia, some clients have asked for a standalone number because when they call 911 and ask for the CRU, police “intercept” their call.⁴⁴In Edmonton, REACH attempts to direct as many 24/7 calls to 211 as possible in order to save 911 callers and dispatchers the time of answering, assessing, and transferring calls; 72% of the program’s 2018 calls were directly to 211 in 2018.⁴⁵EMCOT also receives referrals and has staff at hospitals and the county corrections complex to connect individuals who may be unable to overcome barriers to services post- release.⁴⁶

Call-takers are trained to screen for calls that their crisis-response programs are able to respond to, and assess whether there is a likelihood of violence or danger.⁴⁷A copy of the “911 Dispatch Call-Taking Manual” for CAHOOTS response can be found in section VIII of this report.

Dispatch

Except for Edmonton, where 24/7 partners with 211, each city used its preexisting 911

call center to dispatch calls. In Eugene and Olympia, program workers also carry police radios with the ability to divert calls directly from police, initiate their own interactions, or respond to first responders at a scene to provide assistance.⁴⁸In Austin, EMCOT workers are stationed at the 911 call center⁴⁹with iPads, where they can take calls directly from dispatchers, or from first responders at scenes.⁵⁰ Appendix F is a diagram of the CAHOOTS’ dispatch process.

Diversion from Higher Level of Care/PoliceResponse

CAHOOTS called for police backup in 150 of their 24,000 responses last year, or a rate of 1 in every 160 responses (0.625%).⁵¹They respond to about 70% of their calls without any other first responders.⁵²Last year, CAHOOTS responded to roughly 20% of all calls dispatched by 911 for Eugene and the neighboring city of Springfield.⁵³Appendix C is a table of available response data for CAHOOTS.

98.7% of law enforcement referrals to EMCOT divert from arrest, and 75.1% of EMS referrals divert from emergency- department transfer and admission.⁵⁴EMCOT relieves first responders within 10– 15 minutes after arriving at a scene 85–90% of the time.⁵⁵Arrests of people with mental illnesses in Austin during the program’s first year reduced by 30 percent.⁵⁶Since the program began in 2013, 7,214 clients have been served, with 3,182 dispatches in 2019.⁵⁷

Travis County’s Community Health Paramedics “served 1,164 individuals in fiscal year 2019.”⁵⁸The program is being

expanded, and the county EMS association noted that the city’s recent efforts to decriminalize homelessness have made the program more effective.⁵⁹By 2019, the program had “contributed to a 60 percent reduction in emergency calls from its target population.”⁶⁰

In the first two months of Olympia’s Crisis Response Unit, it responded to about 700 calls.⁶¹

Following the previous “MAP” program, after 4 years of Edmonton’s 24/7 program, it had responded to over 6,000 unique clients and 38,000 crisis events.⁶²In 2019, 25% to 30% of calls were referred to more appropriate services.⁶³Appendix B is a table of available response data for 24/7.

Staff/Training

Each program operates with mobile two-person teams.⁶⁴Programs use vans that are owned by the host organization or the city and filled with supplies.⁶⁵

EMCOT workers are master’s level clinicians.⁶⁶The Community Health Paramedics staff of 15 is divided by the populations they serve (i.e., chronically homeless, elderly, recently incarcerated), and have an average of 15 years of experience.⁶⁷Olympia’s CRU is “made up of nurses and behavioral health specialists.”⁶⁸24/7 workers must have at least two years of experience in delivering community-based services, experience working with partners and stakeholders, and

a knowledge and understanding of poverty- related issues.⁶⁹It is preferred that workers have a degree in social services or a related

field, but candidates who have relevant and related experience are also considered.⁷⁰

Each CAHOOTS team consists of one medic (a nurse, paramedic, or EMT, who must be state certified with at least an EMT-B certification) and a mental health crisis worker who has substantial training and experience in the mental health field, with a degree preferred but not required.⁷¹Some of the medical staff are current nursing students.⁷²Many workers are trained to perform both roles.⁷³Training for CAHOOTS workers lasts “6 months to a year.”⁷⁴Due to their training, in 31 years of the program no staff member has ever been in a major traffic collision or suffered a major injury while responding to a call.⁷⁵“A non-judgmental and client-centered approach to communication and service delivery is emphasized. Trainees begin as observers, watching trained team members handle a variety of calls. They also attend weekly debrief sessions to promote better client care as well as address issues of boundaries, rescuing, and worker self-care in order to avoid burnout. Workers must also pass an extensive background check.”76 On average, the training is 500 hours in the field and up to twenty hours in the classroom.⁷⁷CAHOOTS workers rely on trauma-informed de-escalation and harm reduction techniques.⁷⁸The administrative coordinator of the program said there are a “trifecta” of qualities they look for: technical knowledge in the area of medical and behavioral health; a belief in client-centered care; and personal experience in crisis situations.⁷⁹The coordinator said those qualities are helpful so workers can “bring the level of empathy and compassion to the work that we expect of our workers, and

that that’s a really tricky mix to sometimes find.”80

Job descriptions for the programs can be found at the following links: CAHOOTS Medics, and Crisis Intervention Workers; CRU; EMCOT, 24/7.

Client Data

All of CAHOOTS’ services are confidential, free, and voluntary.⁸¹CAHOOTS workers  log details of their dispatches, including names and addresses of people they interacted with, their mental health diagnoses (if any), and behavioral patterns.⁸²Teams utilize these logs when they are dispatched, allowing them to know what works for specific clients based on past interactions.⁸³ 24/7 workers record their interactions with clients in an app created by REACH to store client information, so the information can be shared between teams in order to best match the needs of clients.⁸⁴ The app also automatically generates reports and maps with the aggregate data.⁸⁵Before creating the app, REACH conducted an impact assessment to determine potential client privacy issues.⁸⁶

Populations Served

Most CAHOOTS clients are experiencing homelessness, and just under a third have a severe mental illness.⁸⁷CAHOOTS also responds to calls from the University of Oregon Eugene Campus⁸⁸and local schools.⁸⁹ Appendix E is a chart with the most common CAHOOTS call factors. 24/7 mostly assists people who are homeless, but some disorder calls for service are diverted from police dispatch to the teams.⁹⁰The City of Edmonton is in the process of analyzing its 911 dispatch data to see how many calls related to mental health, addiction, and homelessness could be diverted to an expanded 24/7 program.⁹¹Of all the people served by EMCOT in 2019, 29% were experiencing homelessness.⁹²

How Programs Got Started

White Bird Clinic, which runs Eugene’s CAHOOTS program, ran a mobile crisis-response program directly through their clinic for years before CAHOOTS began. CAHOOTS has increased from a budget of $288,000 and a staff of 15 in 2010⁹³to a $2.1 million budget⁹⁴and a staff of over 40 in 2020.⁹⁵

The pilot program for Austin’s EMCOT was known as MCOT, and began in 2006 “without engagement from APD or EMS.”⁹⁶ The program grew in 2012 as a result of DSRIP funding.⁹⁷DSRIP is a type of “Medicaid Redesign” which compensates service providers with Medicaid funds to provide services more efficiently.⁹⁸In 2013, Integral Care created the EMCOT (Expanded MCOT) program to be available to on-scene first responders.⁹⁹ Later, EMCOT began to take calls directly from 911 operators and also has clinicians at the 911 Call Center to respond to calls.¹⁰⁰ Unlike other cities’ pilot programs, MCOT still operates as a standalone service.¹⁰¹

Austin’s Community Health Paramedics program was created in 2009 and is a DSRIP program administered by the Travis County EMS.¹⁰²The program is currently being expanded with city funding.¹⁰³

Olympia’s CRU is in its second year and was integrated into the emergency response system from its beginning. For three months before responding to calls on their own, CRU workers co-responded to calls with officers to build trust with officers and the community, and also to make themselves known in the areas they were going to serve.104

MAP, the multiyear prototype for the 24/7 program, was created after a stakeholder assessment and community engagement session and operated without city funding.¹⁰⁵ In 2015, the 24/7 program was created after input from 25 community stakeholders at two separate sessions, and 17 agencies were involved in the development of the new plan.¹⁰⁶Edmonton also does 90-day pilots to test potential changes to the program.¹⁰⁷In 2015, the Edmonton City Council asked REACH about options for expansion and REACH noted that “it would not be a simple linear expansion with identical resource requirements or results for” each neighborhood.¹⁰⁸

Costs/Savings

CAHOOTS “costs on average $71 an hour.”¹⁰⁹REACH estimates that for “every $1 invested in the 24/7 Crisis Diversion initiative, there is a social return on investment (SROI) of $1.91 in the form of savings in health care, policing, and legal costs.¹¹⁰Costs were reduced for ambulance transport, police, and emergency room services.¹¹¹For many clients that these programs serve, the cost of an emergency room visit would otherwise fall on the taxpayer, a cost estimated at $1,010 per visit in 2018 by the Federal Medical Expenditure Panel Survey.¹¹² CRU’s $497,000 annual budget covers supplies and salaries for six behavior health specialists, working in three two-person teams from 7 a.m. to 9 p.m. seven days a week.¹¹³

Travis County (the county encompassing Austin) contributed $1 million to expand MCOT into EMCOT.¹¹⁴ CRU, with its first annual budget of $497,000, estimated $110,100 in startup costs.¹¹⁵The original plan for MAP, the predecessor to 24/7, estimated start-up costs of $892,000 for an annual budget of $2,037,530.¹¹⁶

Wages for the programs are: CAHOOTS:

$18 an hour,¹¹⁷ EMCOT: $150,000 annually for clinicians,¹¹⁸ CRU: $50,992.00 to

$63,745.50 annually,¹¹⁹and 24/7: $20.63 to 24.27 an hour (Canadian dollars).¹²⁰

Appendix A is a table with each city’s police department and crisis response program budgets, response information for both, as well as estimated savings of the crisis response program.

Police Opinions

All of the police departments viewed their crisis-response programs positively; they generally recognize that the workers are better suited to handle certain call types and that when they do it frees up police to work on other matters.¹²¹However, there is generally a period after programs first begin when officers are hesitant to fully defer to it, but do so after seeing the program operate effectively.¹²²In Austin, where the program doesn’t operate 24/7, the EMCOT program manager says law enforcement frequently asks when they will have overnight

staffing.¹²³ EMCOT provides training to the police department in an attempt to form stronger bonds between crisis workers and officers.¹²⁴

Lack of Adequate Funding

Every program (other than Olympia’s Crisis Response Unit, which is in its second year of operation) outgrew the program’s demand at least once.¹²⁵Cities tend to expand programs when they are presented with data about cost savings and hear from community members about the effectiveness of the programs.

Considerations for an Albany Crisis-Response Program

Choosing a Host Organization/Agency

Except for Olympia, each crisis-response program built upon or expanded a preexisting initiative. The programs were administered by nonprofit organizations, either directly or through a subcontract.

Subcontracting may show that the program is “collaborative but separate” from law enforcement, as well as allow for funding streams in addition to those available to municipalities or counties. However, public officials will have less control over the program. When looking for the right organization to administer the program, local governments should look for organizations with (i) a longstanding presence in the community, (ii) a history of delivering similar services, (iii) an ability to track performance and measure success, and

• the ability to store client data safely and follow other statutes and regulations.

CAHOOTS is administered by White Bird Clinic, a Federally Qualified Health Center.¹²⁶Albany has one Federally Qualified Health Center, the Whitney M. Young Junior Health Center,¹²⁷which currently operates “Whitney on Wheels,” a mobile van unit that provides preventative care such as physicals, chronic-disease management, health and nutritional education, lab tests and screenings, and vaccinations at various partner locations.¹²⁸ However, for some of the locations, the client must be a member of the partner organization, and the services are only available to clients who are willing to establish Whitney Young Health as their primary care provider.¹²⁹

EMCOT is administered as part of Texas’ DSRIP (Medicaid redesign) process by Integral Care, one of the members of an Austin DSRIP network.¹³⁰In Albany, the Better Health for Northeast New York PPS (Better Health) is the local DSRIP network.¹³¹One of Better Health’s eleven initiatives includes funding crisis stabilization services.¹³²Within the Better Health network, there are three mobile crisis response programs: the Albany County Department of Mental Health’s Mobile Crisis Team, the Capital District Psychiatric Center’s Crisis Unit, and the Parsons Center’s Capital Region Child and Adolescent Mobile Team.¹³³

Point of Access, Dispatch, Integration with Emergency Response and Service Providers

Crisis-response workers can be dispatched:

• (i)   directly by 911,
• (ii) through a separate number,
• (iii) directly by first responders, or
• (iv) some combination of the above. Based

on the experience of the other programs, having all of the above as points of access would help a program be more successful, with 911 access being the most crucial.¹³⁴CAHOOTS workers have found it extremely beneficial to share radios with the police.¹³⁵ It allows officers to call for crisis-response workers once they’ve assessed a situation, and workers can ‘preempt’ police response when appropriate.¹³⁶

All the programs can refer or transport clients to other social-service providers, some after not being originally able to do so.¹³⁷This allows for direct access to long-term and appropriate care. All programs have a process in place for frequent users of their program in order to provide them more comprehensive services or to refer them to a different provider for a higher level of care.¹³⁸

Potential Funding Sources

• Reallocation of funds from police budget
• Medicaid Redesign (DSRIP) funding
• Federal Funds
  • Department of Justice – Bureau of Justice Assistance – Justice Assistance Grant
    • Community Oriented Policing Services – Community Policing Development, COPS Hiring Program.
  • Housing and Urban Development – Community Development Block Grant
  • The “CAHOOTS” Act - Proposed by members of Oregon’s congressional delegation¹³⁹
• The bill would provide a 95% match in Federal Medicaid funds to states to provide “community-based mobile crisis services,” with additional funding for program planning.¹⁴⁰
• Request the state to provide funding
  • Could be similar to California’s C.R.I.S.E.S. (Community Response Initiative to Strengthen Emergency Systems) bill, passed in July 2020.¹⁴¹
  • Or, like Oregon’s Addiction and Mental Health Crisis Services grant, which allowed CAHOOTS to expand services to Springfield¹⁴²
• NYS Division of Criminal Justice Services Legislative Member Item
• Private fundraising (if the program is hosted by a nonprofit organization)¹⁴³
• Pay for Success Contracts (Social Impact Bonds)¹⁴⁴

Steps to Create a Crisis Response Program

1. Survey Local Needs
2. Convene Organizational Stakeholders
   1. Appendix G is a list of potential local stakeholders
3. Survey people from target populations
   1. Include them in design process
4. Analyze call data¹⁴⁵to see:
   1. what call types the crisis response program may respond to,
   2. the frequency of those call types,
   3. locations where calls most often originate from (by police beat, census tract, etc.), and
   4. what times of day those calls are most common.
5. Decide on Program Operations, Structure, and Funding
   1. Solicit feedback from community and stakeholders on design
   2. Decide on metrics to monitor program and measure success
   3. Pursue various funding streams
6. Reallocate Police Funding Towards Program
   1. Here is a detailed Austin City Council hearing about the costs of the then-proposed EMCOT program. Appendix D is a table of police department spending and outcomes for Albany and other municipalities in New York.
7. Issue Request for Proposals (If Subcontracting)
   1. The Request for Proposals should incorporate the takeaways from the first two steps. Job descriptions for the programs can be found at the following links: CAHOOTS Medics, and Crisis Intervention Workers; CRU; EMCOT,24/7.
8. Train 911 Call-Takers and First Responders on the Role and Functions of the Crisis- Response Program
   1. All 911 call-takers should be trained to screen for calls that the program will be able to respond to. In Austin, 911 operators are trained to ask whether the caller needs police, fire, or mental health services.¹⁴⁶A copy of the “911 Dispatch Call-Taking Manual” for CAHOOTS response can be found in section VIII of the report.
   2. Police have policies and procedures on how to interact, and in some cases defer to, the crisis response programs in their cities.¹⁴⁷
9. Start Pilot, Scale Up, Make Changes
   1. Because other programs have suffered due to lapses in funding, local governments should be ready to authorize mid-year funding increases. This also gives governments additional oversight of nonprofit subcontractors. The program should be collecting enough data on an ongoing basis to analyze, and if necessary, modify its operations.

Conclusion

Currently, local governments have a unique opportunity to reimagine public safety and health, and potentially realize significant savings in doing so. These savings can be reallocated to address root causes of crime and poverty, reducing the needs for services over time. As shown, there is not one way to administer a crisis-response program.¹⁴⁸ However, constants among these programs examined can inform local governments in their own efforts to start similar initiatives.

Takeaways from these programs are to (i) include stakeholders in the program design process, (ii) aim to build trust within the police department and community, (iii) have a designated place within the 911 and emergency response processes, (iv) have adequate funding with access to mid-year

increases if necessary, (v) have a capable host organization/agency and be appropriately administratively housed, (vi) properly train employees, 911 call-takers, and other first responders, (vii) use past and current call data to inform operations, and have the ability to transfer or refer clients to other service providers.

Appendix A: Comparison of Police and Crisis Response Budgets, and Estimated Savings

Data is for 2019, unless indicated otherwise

*2018

**2017

Appendix B: Edmonton’s 24/7 Crisis Diversion Program Response and Cost Data

Appendix C: Response and Diversion Data for Eugene’s CAHOOTS Program

Appendix D: Police Spending and Outcomes for Several Cities in New York

Appendix E: CAHOOTS Most Common Call Factors²²²

Appendix F: Diagram of CAHOOTS Dispatch Process²²³

Appendix G: List of Potential Albany Stakeholders

Crisis Response Programs

• Capital District Psychiatric Center – Crisis Intervention Unit
  • Albany County Department of Mental Health
    • Mobile Crisis Team
    • Assertive Community Treatment
  • Northern Rivers – Child and Adolescent Mobile Crisis Team

911 and First Responders

• 911 Call Center
• 911 Coordinator Association
• Albany County Sheriff’s Emergency Medical Services Unit (EMS)
  • Director
  • Paramedics/Ambulance Drivers
• City of Albany Fire Department
• Albany Police Department
  • Crisis Intervention Team
  • Law Enforcement Assisted Diversion (LEAD)
• Albany County Sheriff’s Office
• Albany Police Officers Union

Housing Service Providers

• Joseph’s House & Shelter – Albany Outreach Van
• CARES of NY, Inc.
  • They run the Homeless Management Information System (HMIS) for Albany County, and coordinate the Albany Continuum of Care (“The Albany County Portion of the Capital Region HMIS collects client level data from 94 programs operated by 21 agencies.”) (link 2)
• The Albany Housing Coalition, Inc.
• Albany Housing Authority
• Albany County Coalition to End Homelessness
• Interfaith Partnership for the Homeless
• Homeless and Travelers Aid Society
• Mercy House
• Capital City Rescue Mission
• The Salvation Army

Mental Health Service Providers and Advocacy Organizations

• Albany County Department of Mental Health
  • Community Mental Health/Criminal Justice Team
  • Mobile Crisis Team
  • Assertive Community Treatment
  • Albany County Community Services Board
• Provides input to the Department of Mental Health and its Director; helps to create the annual local services plan, outlining Albany mental health services.
• Albany County Patient Services Coordinating Committee
• iAlbany County Department of Mental Health and Department of Social Services coordinate services “for people identified as frequent users of expensive crisis services across different public agencies,”²²⁴with “196 individuals served since program inception (2005) with total cost savings of $2,658,476” by late 2020.”²²⁵
• Albany Living Room
• Northern Rivers Behavioral Health Center
• Mental Health Association of New York State
• New York Association of Psychiatric Rehabilitation Services, Inc.
• National Alliance on Mental Illness (Capital Region Chapter)
• New York State Conference of Local Mental Hygiene Directors, Inc.

Other Health and Service Providers

• Albany County Department of Health
• Better Health for Northeast New York (DSRIP for Albany)
• Northeastern Action Community Partnership
  • Capital Region addictions resource collaborative
• Rehabilitation Support Services
• St. Peter’s Addiction Recovery
• Albany Medical Center
• St. Peter’s Hospital
• Albany Memorial Hospital
• Re-Entry Service Providers
  • Trinity Institution
  • Center for Employment Opportunities
  • Prisoners’ Legal Services
  • Prison Families of New York

Government Officials

• Mayor’s Office
  • Crisis Line
• Director of Emergency Operations
• City and County Law Departments
• District Attorney
• 911 Center Director

Additional Groups or Types of Individuals to Get Input From

• Equinox (Domestic Violence Services)
• New York State Office of Addiction Services and Supports
• Center for Law and Justice
• New York State NAACP
• Mental Health Association of New York State
• National Association of Social Workers (New York State Chapter)
• Legal Aid Society of Northeastern New York
• Local Business and Neighborhood Associations
• Emergency Room Staff
• Health Law Attorneys
• Mental Health Counselors
• Behavioral Psychiatrists

Endnotes

* Matt DeLaus is in his second year of dual studies for the J.D./M.P.A. program at Albany Law School and SUNY Albany’s Rockefeller College of Public Policy. He is an Albany Law School Government Law Center Fellow and intern, a subeditor for the Albany Government Law Review, and a recipient of both an Albany

Law School President’s Scholarship and The Arthur F. Mathews '62 Endowed Memorial Scholarship. He cannot fully express his gratitude to Ruchi Patel and Professor Ava Ayers for their support in this work.

1 at 2.

2 In a June interview, Albany Chief of Police Eric Hawkins said “[f]undamentally I don’t have a problem with the basic premise to defund the police, and that is police officers should be doing police work and not social work. Police officers shouldn’t be the point of contact for individuals with mental health issues, substance abuse issues, or unhealthy family structural issues.” https://cbs6albany.com/news/local/activists-call-for-albany-to-defund-the-police-reinvest-into-the-community.

3 See, infra, “Diversion from Higher Level of Care/Police Response;” Appendix B (table of Edmonton’s program responses); Appendix C (table of Eugene, Oregon program response).

4 Cities with non-police crisis response programs in operation less than a year include Portland, Oregon, and Denver, Colorado. See https://www.usatoday.com/story/news/nation/2020/06/22/defund-police-what-means-black-lives-matter/3218862001/. Oakland, California, decided to fund a crisis response program, but it is not yet in operation. See https://www.kron4.com/news/bay-area/mobile-response-unit-coming-to-oakland-to-help-with-non-violent-911-calls. Local governments that have decided to fund a crisis response program since George Floyd’s killing include Los Angeles, California (https://www.cnn.com/2020/10/14/us/los-angeles-unarmed-crisis-response-teams-911-calls/index.html); Miami-Dade County, Florida (http://www.miamidade.gov/govaction/legistarfiles/Matters/Y2020/201239_Analysis.pdf; http://www.miamidade.gov/govaction/legistarfiles/Matters/Y2020/201239.pdf); Philadelphia, Pennsylvania (https://philadelphia.pa.networkofcare.org/mh/news-article-detail.aspx?id=116033); Rochester, New York (https://www.rochesterfirst.com/news/local-news/watch-live-mayor-warren-to-announce-crisis-intervention-program/); Salt Lake City, Utah; Albuquerque, New Mexico; Hartford, Connecticut; Durham, North Carolina (https://www.prainc.com/wp-content/uploads/2020/08/PoliceReformAcrossUS508.pdf at 2-4); and San Francisco, California (https://www.usatoday.com/story/news/nation/2020/06/22/defund-police-what-means-black-lives-matter/3218862001/). Many others are exploring the possibility. See, e.g., https://www.prainc.com/wp-content/uploads/2020/08/PoliceReformAcrossUS508.pdf.

5 CAHOOTS: https://www.salemreporter.com/posts/1584/you-want-a-resolution-as-much-as-possible-six-hours-with-eugenes-mobile-crisis-intervention-team; EMCOT: https://www.austintexas.gov/edims/document.cfm

?id=343511 (draft agreement between Integral Care and the City of Austin and its police department);

CRU:

(Olympia’s request for proposals); and 24/7: https://www.edmonton.ca/

city_government/documents/2016_-_2018_OPERATING_BUDGET.pdf (annual spending of $1 million per year on 24/7 program).

6 Since George Floyd was killed, CAHOOTS has gotten “over 150” requests for information from different cities. https://www.klcc.org/post/national-interest-cahoots-swamps-white-bird-clinics-inbox.

7

8 (presentation by the White Bird Clinic about CAHOOTS to the Oregon state legislature).

9 Texas enabled the creation of Local Behavioral Health Authorities “to provide mental health and chemical dependency services.” Tex. Health & Safety Code Ann. § 533.0356(a) (West).

10 See https://integralcare.org/en/about-us/ (information about Integral Care); https://integralcare.org/wp-content/uploads/2019/03/Local-Behavioral-Health-Authority-faq-011619.pdf (information about Texas’ Local Behavioral Health Authorities).

11 See https://integralcare.org/wp-content/uploads/2020/06/CLEAN-Form-O-CLSP-J… at 60.

12 See https://www.kvue.com/article/news/community/what-does-a-community-health-paramedic-do/269-b8504edf-2b69-4d35-aae9-32052bddcaeb.

13 Albany does not have a health-related special district. (New York State Comptroller’s list of local government entities). See also N.Y. Pub. Health Law §§ 390-99 (Unconsolidated Health Districts).

14 See http://www.austintexas.gov/edims/document.cfm?id=245089 (agreement about Community Health Paramedics program between Travis County Healthcare District and City of Austin).

15

16

17 See https://www.edmonton.ca/city_government/documents/PDF/City_of_Edmonton_Operating_Budget

_Overview_2014.pdf at 466 (“Founded in June 2010, REACH is membership driven, led by a Board of Directors with more than 200 members, encompassing 83 organizations and more than 120 citizens.”); See generally Lynda Frost & Susan Stone, Community-Based Collaboration: A Philanthropic Model for Positive Social Change, 1 THE FOUND. REV. 55-68 (2009) (describing benefits of a coordinating organization to guide social impact efforts). See also https://www.edmonton.ca/city_government/documents/OperatingQuestionsByCouncillor.pdf at 197 (“24/7 is aligned with HUoS, Homeless on Public Land, Capital City Clean Up Needle Collection, YEG Ambassadors, and City Centre Paramedic Response Unit, amongst others.”); https://globalnews.ca/news/3583347/edmonton-heat-wave-has-inner-city-agencies-gearing-up-to-help-the-homeless/ (24/7 works with the city during cold and heat emergencies).

18 (detailing job purpose and responsibilities from Boyle Street Community Services in hiring program workers for 24/7 Crisis Diversion program).

19 See generally https://truthout.org/articles/911-services-that-dispatch-mental-health-counselors-not-cops-gain-traction/. See also https://integralcare.org/wp-content/uploads/2018/04/IntegralCare2017AnnualReport.pdf at 10 (EMCOT works with the Texas Department of Public Safety for responses at the state capitol building).

20 (as of 2019, the Albany Police Department was “continuing the process of having all [their] patrol officers trained in a 40-hour block of Crisis Intervention Team (CIT) training.”); see also Michael S. Rogers, et al., Effectiveness of Police Crisis intervention Training Programs, 47 J. Am. Acad. Psych. Law 414-421, 414 (2019), http://jaapl.org/content/jaapl/47/4/

414.full.pdf (“Studies generally support that CIT has beneficial officer-level outcomes, such as officer satisfaction and self-perception of a reduction in use of force. CIT also likely leads to prebooking [or post- arrest] diversion from jails to psychiatric facilities. There is little evidence in the peer-reviewed literature, however, that shows CIT’s benefits on objective measures of arrests, officer injury, citizen injury, or use of force.”).

21  (the Albany County Department of Mental Health 2020 local services plan found that “the level of need” for crisis services “is outweighing the available resources, time and expertise needed.”).

22

23 See, e.g., http://www.austintexas.gov/sites/default/files/files/Auditor/Audit_Reports/APD_Response_to_Mental_Health_Related_Incidents September_2018.pdf at 13 (“[a]ccording to APD and Integral Care, EMCOT is useful for mental health calls where an officer’s presence is no longer required or where the officer’s presence may be detrimental to the situation. These incidents are low-risk from a safety perspective, but may be complex from a diagnostic perspective.”).

24 See https://www.kvue.com/article/news/community/what-does-a-community-health-paramedic-do/269-b8504edf-2b69-4d35-aae9-32052bddcaeb.

25 CAHOOTS:

(describing various CAHOOTS services). EMCOT: “Services include mental health support for up to 90 days and care plans to help keep people safe. Clients are also connected to other Integral Care programs and local resources for ongoing care and recovery support.” https://integralcare.org/program/mobile-crisis-outreach-team-mcot/. 24/7: In 2019, Edmonton City Council approved funding “to enhance warm hand-offs for people and referrals of individuals with complex needs to multi-agency services. This pilot involved ethnographic research, which is helping us better understand who the clients are and what specific barriers they face so gaps in services can be directly addressed.” https://reachedmonton.ca/wp-content/uploads/2020/06/2019_REACH_Annual_Report_Single.pdf.

26 CAHOOTS: Workers provide training as part of its response to crisis events, as well as upon request. CAHOOTS is able to train individuals in skills to help them manage crises. See https://www.gq.com/story/how-a-911-call-without-police-could-work. Staff also trains the police department for their forty-hour Crisis Intervention Team training. EMCOT has “provided training for 1,500 law enforcement officers, EMS, and school resource officers.” https://integralcare.org/en/2019/10/

17/city-of-austin-budget-announcement/.

27 See e.g.,

28 See https://www.klcc.org/post/cahoots-30-pt-ii-services-expand-other-cities-take-note-its-intervention-model.

29 See https://www.gq.com/story/how-a-911-call-without-police-could-work.

30

31 See the “Crisis Response Host Organizations” section.

32 See note 24.

33 EMCOT and Community Health Paramedics collaborate to assist the most frequent users of their services. See https://www.kvue.com/article/news/community/what-does-a-community-health-paramedic-do/269-b8504edf-2b69-4d35-aae9-32052bddcaeb. See also https://www.kvue.com/article/news/austin-ems-needs-more-ambulances/269-d486a9ee-9f17-4ebf-8f95-f888cfc9c698 (describing services provided by Community Health Paramedics).

34 See City of Olympia, Crisis Response & Peer Navigators

35

36

37 See http://oregon.granicus.com/MediaPlayer.php?clip_id=28302, at 20:14–21:00.

38 See e.g., CRU: Olympia’s local buprenorphine clinic called CRU for a person experiencing issues with the detox process, and said afterwards “CRU quickly established rapport and defused the situation.”

39 REACH conducted a marketing campaign encouraging callers to call 211 instead of 911 for people in crisis. See https:// reachedmonton.ca/initiatives/24-7-crisis-diversion/. In 2018, 72% of the program’s referrals came from 211. See REACH Edmonton, 2018 Annual Report. That was up from 36% in 2016. See https://issuu.com/reachedmonton/docs/reach_

annualreport_impact2017_web_m at 4.

40 See CAHOOTS: https://police.uoregon.edu/faq#cahoots (“For safety reasons, CAHOOTS does not respond directly to calls from members of the public.”). EMCOT: https://www.austintexas.gov/edims/document.cfm?id=

302634.

41(“CRU . . . will respond to certain 911 calls.”).

42 See https://integralcare.org/wp-content/uploads/2017/07/Mobile-Crisis-Outreach-Team_MCOT.pdf (the standalone MCOT phone line housed in Integral Care). See also https://www.austintexas.gov/edims/document.cfm?id=302634.

43 See https://www.nytimes.com/2020/06/08/us/what-does-defund-police-mean.html.

44 https://www.themarshallproject.org/2020/07/24/crisisresponders ( “. . . CAHOOTS is considering creating a separate emergency number for people to use if they’re uncomfortable calling 911”).

45 See note 38.

46 See Bailey Douglas Gray, Breaking the Cycle: Evidence-Based Diversion for Homeless Individuals with Mental Illness, University of Austin Master’s Thesis at 64–65 (Aug. 2019), https://repositories.lib.utexas.edu/bitstream/

handle/2152/78603/GRAY-MASTERSREPORT-2019.pdf?sequence=1&isAllowed=y (“This service is available across Travis County which means EMCOT may be requested by EMS, the Travis County Sheriff’s

Office, Lakeway Police, the Department of Public Safety, and Travis County Sheriff’s Office administrators at the Travis County Correctional Complex and Central Booking.”) [hereinafter Gray].

47 See CAHOOTS: https://whitebirdclinic.org/wp-content/uploads/2020/07/CAHOOTS-Media.pdf at 1 (“Dispatchers are trained to recognize non-violent situations with a behavioral health component, and route those calls to CAHOOTS.”); https://www.kgw.com/article/news/investigations/a-new-answer-to-911-portland-could-soon-send-street-response-teams-instead-of-police/283-a94bb69e-5cf4-4f75-bbc8-7941370c04f7 (“Operators are trained to ask questions aimed at deciding whether a sending an officer is truly necessary.”). EMCOT: Starting recently, “[a]s long as there’s no weapon present and no sense of ‘imminent death or harm to self or others,’ . . . 911 callers can be transferred from the Austin police to the crisis team. EMCOT is automatically dispatched to” most mental health calls. https://truthout.org/articles/911-services-that-dispatch-mental-health-counselors-not-cops-gain-traction/.

48 CAHOOTS: One worker said “we can hop on the radio and say like, ‘Hey, it doesn't sound like there's a crime happening, so we’ll spin around the block and we’ll go check in ... and let you know if any patrol is needed for that.’ We're able to respond to calls that come into dispatch on 911 . . . We can’t get those calls if we’re not plugged into that system the same way.” One officer recalled how officers felt about CAHOOTS when the program began, which was generally “[w]e’ve got these long-haired hippie guys driving around in a van . . . They’re on our police radios. Something’s not right.”

49 There is a similar program in Broome County, New York, There, 911 calls about someone experiencing a mental health crisis are transferred directly from 911 call-takers to trained mental health counselors. If the situation escalates, the call is transferred back to 911 call-takers to dispatch law enforcement. See https://meetny.webex.com/recordingservice/sites/meetny/recording/014f7ea5ac10478d9eddd3eefe0c123d (presentation from the CIT coordinator for Broome County about the program); https://nyscit.org/wp-content/uploads/2019/10/Broome-County-911-Diversion.pptx (slides from that presentation).

50 “EMS will soon also employ a tool called Telehealth” and “hire two full-time and one part-time clinician who will be able to answer video calls from paramedics or crisis intervention officers.” https://www.kxan.com/news/local/

austin/city-of-austin-budget-makes-effort-to-focus-on-mental-health-improvements/; “EMCOT team members will be stationed at the 911 Call Center, where mental health calls will be transferred by 911 call takers to EMCOT.” https://integralcare.org/en/2019/10/17/city-of-austin-budget-announcement/. See also https://www.austintexas.gov

/edims/document.cfm?id=326169 at 27 (clinicians can be first responders for calls with little to no danger).

51 See https://www.npr.org/2020/06/10/874339977/cahoots-how-social-workers-and-police-share-responsibilities-in-eugene-oregon.

52 See https://www.wbur.org/hereandnow/2019/03/12/eugene-oregon-mental-health.

53 See https://www.npr.org/2020/06/10/874339977/cahoots-how-social-workers-and-police-share-responsibilities-in-eugene-oregon.

54 See https://www.austintexas.gov/edims/document.cfm?id=302634; see also https://truthout.org/articles/911-services-that-dispatch-mental-health-counselors-not-cops-gain-traction/; Gray, note 47 at 64-65.

55 See https://www.austinchronicle.com/news/2017-12-15/how-austin-handles-mental-health-emergencies/.

56 See https://www.kvue.com/article/news/local/travis-county-program-keeping-people-struggling-with-mental-health-out-of-jail-could-lose-funding/269-581536576.

57 See https://integralcare.org/en/2019/10/17/city-of-austin-budget-announcement/ (7,214 individuals

since 2013); https://truthout.org/articles/911-services-that-dispatch-mental-health-counselors-not-cops-gain-traction/ (dispatched 3,182 times).

58 https://truthout.org/articles/911-services-that-dispatch-mental-health-counselors-not-cops-gain-traction/.

59 See https://www.kvue.com/article/news/austin-ems-needs-more-ambulances/269-d486a9ee-9f17-4ebf-8f95-f888cfc9c698.

60 Gray, note 47 at 64.

61 See https://mynorthwest.com/1404341/olympia-crisis-response-unit-homeless/.

62

63 See https://reachedmonton.ca/wp-content/uploads/2020/05/2019-REACH-Business….

64 The CAHOOTS administrator said the following:

“I think one of the primary things is the medic and crisis worker combination is what has allowed us to make such significant impacts in our community. By recognizing that behavioral health has a role in physical health, and physical health has a role in behavioral health, you're able to really kind of treat the whole patient. And there are a lot of folks out there where maybe they don't have the upbringing or the background to be able to articulate when they're not feeling well emotionally, but they will reach out to say, "My stomach hurts" – and so [you're] having that medic become this way for folks to [really] open up about what they're experiencing emotionally.”

65 CAHOOTS: The City of Eugene provides funds to the program, “covering its staff and vans.” 24/7: Vans are owned by REACH, with one donated by local businesses. See https://edmonton.ctvnews.ca/24-7-crisis-diversion-team-ready-to-roll-thanks-to-donated-ride-1.4455017.CHP workers use EMS ambulances which they return at the end of their shifts. See https://healthiertexassummit.com/wp-content/uploads/2018/10/Advancing-Homeless-Healthcare-with-Community-Health-Paramedics.pdf at 17.

66 Gray, note 47 at 64.

67 See generally https://www.kvue.com/article/news/community/what-does-a-community-health-paramedic-do/269-b8504edf-2b69-4d35-aae9-32052bddcaeb (team specialists “work with seniors” and

with “people who are incarcerated”); https://truthout.org/articles/911-services-that-dispatch-mental-health-counselors-not-cops-gain-traction/ (some CHP workers specialize in homelessness).

68

69

70 See id.

71 See https://truthout.org/wp-content/uploads/legacy/documents/starting_a_MCIP.pdf (starting a “Mobile Crisis Intervention Program”);

68512 (presentation to Oregon legislature).

72 See https://www.gq.com/story/how-a-911-call-without-police-could-work.

73 Id.

74 https://truthout.org/wp-content/uploads/legacy/documents/starting_a_MCIP.pdf.

75 See https://www.kgw.com/article/news/investigations/a-new-answer-to-911-portland-could-soon-send-street-response-teams-instead-of-police/283-a94bb69e-5cf4-4f75-bbc8-7941370c04f7.

76 https://www.gq.com/story/how-a-911-call-without-police-could-work.

77 See

78 See

79 https://www.eugene-or.gov/DocumentCenter/View/47955/In-Cahoots---How-the-unlikely-pairing-of-cops-and-hippies-became-a-national-model-Register-Guard---Oct-20-2019.

80 Id.

81 See, e.g., https://kval.com/news/local/theres-a-growing-awareness-that-alternatives-to-law-enforcement-are-needed.

82 See https://www.pubadvocate.nyc.gov/reports/improving-new-york-citys-responses-to-individuals-in-mental-health-crisis/ (New York City Public Advocate Jumaane Williams’ report recommending ways to improve New York City’s mental health crisis response, looking at CAHOOTS).

83 See id. In the report, New York City Public Advocate Jumaane Williams said using these logs “is crucial in minimizing unproductive and potentially violent encounters.”

84 “24/7 Crisis Diversion partners Boyle Street Community Services and HOPE Mission agreed to use the 24/7 Edmonton App in 2016 with their front-line staff in the field to record their work and the nature of those encounters with vulnerable people.” https://reachedmonton.ca/wp-content/uploads/2020/05/2020-REACH-Business-Plan_FINAL.pdf. In 2019, “[f]ront line 24/7 Crisis Diversion staff from partners BSCS & HOPE Mission inputted 13,955 non-crisis events into the 24/7 app. This information was shared amongst six teams to align their support to clients.” https://reachedmonton.ca/wp-content/uploads/2020/05/2019-REACH-Business-Plan-Report-Back_REV.pdf at 28. “[T]he largest hurdle to clear was the issue of privacy protection. The involvement of the” Canadian government office of privacy oversight “was vital to getting the app from concept to reality.” https:/

/www.edmonton.ca/city_government/documents/2016_-_2018_OPERATING_BUDGET.pdf at 591.

REACH “[c]ompleted a Privacy Impact Assessment (PIA) with the Office of the Privacy Commissioner.”

reach/24:7_Edmonton_App_Flyer.pdf.

85 https://youtu.be/BuVP9b15r4g?t=1465 at 24:25.

86 See id.

87 See https://whitebirdclinic.org/wp-content/uploads/2020/07/CAHOOTS-Media.pdf (“More than 60% of our clients are homeless, and 30% live with severe and persistent mental illness (SPMI).”).

88 See https://police.uoregon.edu/faq#cahoots (“The department works hand-in-hand with CAHOOTS on a regular basis, recognizing that police officers are not the appropriate resource to respond to every situation.”).

89 See http://projects.registerguard.com/rg/2017/jun/07/a-safe-place-to-go/.

90 See https://issuu.com/edmontonpolice/docs/2016_q4_app_public at 10.

91 See https://edmontonjournal.com/news/local-news/edmonton-city-council-approves-20-actions-for-police-service-reform-including-11m-budget-cut-over-two-years.

92 See https://truthout.org/articles/911-services-that-dispatch-mental-health-counselors-not-cops-gain-traction/.

93 See Jack Moran, “Second ‘Intervention’ Van Funded, THE REGISTER GUARD (Mar. 4, 2011) (in 2011, contract “doubled” to $566,000) (on file with author).

94 See https://whitebirdclinic.org/wp-content/uploads/2020/07/CAHOOTS-Media.pdf at 1.

95

96 See Gray, note 47 at 64–65.

97 See id.; https://www.austintexas.gov/edims/document.cfm?id=302634 at 2 (“EMCOT was established through Integral Care’s Delivery System Reform Incentive Payments (DSRIP) program through the 1115 Medicaid Transformation Waiver”).

98 See generally https://youtu.be/lBgRH3ITUjU (presentation and panel discussion about New York’s DSRIP program).

99 See Gray, note 47 at 64–65.

100 “EMCOT began integrating their clinicians with APD 911 Call Center on December 16, 2019, to facilitate mental health crisis calls and divert from unnecessary police response.” https://integralcare.org/wp-content/uploads/2020/

06/CLEAN-Form-O-CLSP-June-15_2020.pdf.

101 See Gray, note 47 at 64–65.

102 See https://www.ccc-ids.org/wp-content/uploads/2015/06/RHP07_307459301.2.6_201502.pdf.

103 See https://www.kvue.com/article/news/austin-ems-needs-more-ambulances/269-d486a9ee-9f17-4ebf-8f95-f888cfc9c698.

104

105

106 See https://issuu.com/reachedmonton/docs/2015_reach_annual_report at 4.

107 See https://www.edmonton.ca/city_government/documents/APPROVED_2019-2022_OPERATING_BUDGET

.pdf at 640.

108 https://www.edmonton.ca/city_government/documents/2016-18%20Operating%20Budget%20Council

%20Questions.pdf at 19.

109 https://www.marketwatch.com/story/long-before-defund-the-police-mental-health-advocates-have-been-redefining-public-safety-2020-06-11.

110 See https://www.edmonton.ca/city_government/documents/APPROVED_2019-2022_OPERATING_BUDGET

.pdf at 641.

111 See https://whitebirdclinic.org/wp-content/uploads/2020/07/CAHOOTS-Media.pdf at 5.

112 See https://www.meps.ahrq.gov/mepsweb/data_stats/download_data/pufs/h206e/h206edoc.pdf at C- 20.

113

114 See https://www.traviscountytx.gov/images/planning_budget/Docs/adopt_vol1.pdf at 49.

115

116 See https://webdocs.edmonton.ca/siredocs/published_meetings/11/65599.pdf at 14.

117 See

118 See http://www.austintexas.gov/edims/pio/document.cfm?id=320044 at 47 (“$450,000 for three additional licensed EMCOT clinicians.”); http://www.austintexas.gov/edims/pio/document.cfm?id=320044 at 45 (“$300,000 [c]osts include salary, fringe benefits, and supplies for two licensed Call Center Clinicians.”).

119 See

120

121 See e.g., CAHOOTS: An officer who began her career after CAHOOTS was created said “I actually have never worked in an environment without CAHOOTS, and I don’t know how it would be possible to do what we do as successfully as we do without them.” https://www.klcc.org/post/cahoots-30-pt-ii-services-expand-other-cities-take-note-its-intervention-model One officer, who declined to give his name because he wasn’t authorized to speak to media, said CAHOOTS is “able to respond to a lot of calls we [the police] maybe shouldn’t respond to,” and that he would ”strongly recommend” a crisis response program. https://www.salemreporter.com/posts/1584/you-want-a-resolution-as-much-as-possible-six-hours-with-eugenes-mobile-crisis-intervention-team. The Eugene chief of police calls the program a “symbiotic relationship.” https://www.cnn.com/2020/07/05/us/cahoots-replace-police-mental-health-trnd/index.html. The chief also testified before the Oregon Legislature’s Joint Committee on Transparent Policing and Use of Force Reform that the program is about “matching the response with what is needed in the community,” and that “all of North America is calling us.” http://oregon.granicus.com/MediaPlayer.php?clip_id=

28302 at 17:00–24:00.

122 One of the CAHOOTS co-founders said at first, they “sort of had to prove [themselves] . . . It took maybe a year or two for the police and the wider community to get the idea of what CAHOOTS was and how they could use us.” However, the current CAHOOTS administrator said "[a]t this point, we’ve patiently waited out an entire generation of police officers . . . It’s been that slow of a process.” https://www.cnn.com/2020/07/05/us/

cahoots-replace-police-mental-health-trnd/index.html. CRU: The outreach services coordinator for the police department said for the program to build community trust, it had to prove it is “collaborative but separate” from law enforcement. https://www.themarshallproject.org/2020/07/24/crisisresponders. At the same time, the program has to build trust with the police department, with one CRU worker saying “I think they’re hesitant to let us just show up . . . They’re worried about our safety. But the cops are becoming more aware. We’ve been out here for over a year and none of us have been assaulted.” Id. Other workers say that police are deferring more calls to them and trusting them in a wider range of circumstances. See id.

123 See Gray, note 47 at 64–65.

124 See https://integralcare.org/en/transparencies-3/.

125 CAHOOTS: From 1989 to 2011, the program consisted of one van that did not operate 24/7; the budget has subsequently been increased year over year because of demand for CAHOOTS’ services. See Jack Moran, “Second ‘Intervention’ Van Funded, THE REGISTER GUARD (Mar. 4, 2011) (on file with author). “Based on call volume, demand for CAHOOTS services has increased by over 58% from 2014-2017.” https://www.indybay.org/newsitems/

2020/07/02/18834819.php. EMCOT: The program was expanded from a previous program that was not part of the first response structure. See Gray, note 47. 24/7: In 2014-2015, the previous crisis diversion program only had enough funding to respond to 5% of the disorder calls they could have otherwise responded to. See https://www.edmonton.ca/city_government/documents/2016-18%20Operating%20Budget%20Council

%20Questions.pdf at 19. “In 2018, the first seven months of delivery of 24/7 Crisis Diversion shows demand at an average of 26% above funded capacity.” https://www.edmonton.ca/city_government/documents/APPROVED_

2019-2022_OPERATING_BUDGET.pdf at 639.

126 “The clinic is a Federally Qualified Health Center.” https://whitebirdclinic.org/wp-content/uploads/2020/07

/CAHOOTS-Media.pdf. For information on Federally Qualified Health Centers, see

https://www.fqhc.org/what-is-an-fqhc.

127 See CMS PUB 45-4 § 4231, 2015 WL 7936143 (Center for Medicare and Medicaid Services Manual, listing Federally Qualified Health Centers).

128 See https://www.wmyhealth.org/services/whitney-wheels/; https://www.wmyhealth.org/services/whitney-wheels/#tabcontainer-1029-757.

129 See id.

130 See Gray, note 47 at 64–65.

131 See https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/pps_map/county/co_albany.htm (although there is also the Alliance for Better Health, it is focused around Schenectady).

132 Reference link no longer active.

133 See http://www.clmhd.org/img/uploads/2020_Mental_Hygiene_Local_Services_Plan_Guidelines.pdf at 9.

134 24/7 workers are dispatched through 211, and the manager of the 24/7 program says it is “crucial” that 211 is used so the “community feels empowered to respond.” In order to get Edmontonians to use 211, REACH ran a marketing campaign. See https://reachedmonton.ca/initiatives/24-7-crisis-diversion/. REACH is looking into the possibility of workers being dispatched directly by 911. On the other hand, CAHOOTS’ White Bird Clinic is looking at the possibility of the program having a standalone number, in addition to being dispatched directly by 911. In Olympia, clients wish there was a number other than 911 they could call. See https://www.themarshallproject.org/2020/07/24/

crisisresponders.

135  See note 47.

136  See note 22.

137  See note 24.

138 Id.

139 See https://www.congress.gov/bill/116th-congress/senate-bill/4441/titles?r=21&s=1 (Senate version); https://www.congress.gov/bill/116th-congress/house-bill/7961?s=1&r=4 (House version).

140 See

141 See https://calmatters.org/justice/2020/07/police-mental-crisis-response-california/.

142 See note 52.

143 CAHOOTS: Examples of fundraisers the White Bird Clinic has hosted for CAHOOTS can be found at https://whitebirdclinic.org/category/fundraising/fundraising-2/. 24/7 “has leveraged over $1 million of in-kind contributions from the partner agencies.” https://reachedmonton.ca/wp-content/uploads/2020/05/2020-REACH-Business-Plan_FINAL.pdf at 28.

144 These arrangements are relatively new in the world of social-service financing, and aim to “invest” in programs that address root causes of social issues, thereby reducing long-term spending on social services. See generally https:/ /golab.bsg.ox.ac.uk/the-basics/impact-bonds/; https://youtu.be/nna8Mu-0o1E. The parties consist of (i) a service provider, (ii) one or more third-party financiers, and (iii) a government backer. The parties sign an agreement outlining specific metrics to determine the program’s success, and the service provider uses the financier’s funds. If the program meets the metrics, the government then pays back the financier, with interest. If the program does not meet the metrics, the government does not pay. This arrangement (a) allocates risk for innovative social programs to be placed with third parties, (b) allows government to distribute their payments to the third-party over time for a successful program, instead of the all-at-once funding associated with implementing the program itself, and (c) a properly constructed agreement will produce data for the length of the arrangement, which can then be used when reallocating funding for other programs.

145 A report for the city of Austin analyzing their 911 call data in this manner can be found at http://www.austintexas.gov/edims/pio/document.cfm?id=320044 at 4-25.

146 See https://www.nytimes.com/2020/06/08/us/what-does-defund-police-mean.html.

147 See e.g., CAHOOTS: See Eugene Police Department Policy 311, Non-Criminal Detoxification, https://www.eugene-or.gov/ArchiveCenter/ViewFile/Item/4314; Eugene Police Department Policy 418, Mental Health Crisis Response, https://www.eugene-or.gov/ArchiveCenter/ViewFile/Item/4339; Eugene Police Department Procedure 3.15, Death Notification, https://www.eugene-or.gov/ArchiveCenter/ViewFile/Item/4399.

148 The CAHOOTS administrator said that “CAHOOTS isn't some cookie-cutter [program] that you can just pick up from Eugene and just kind of plunk down in Houston and expect it to work the same, just bigger.”

149 These numbers were based on the most recently available data, See, https://www.eugene-or.gov/ArchiveCenter/

ViewFile/Item/5910 at 37 (137,087 calls for service, 31,685 officer-initiated); https://www.springfield-or.gov/wp-content/uploads/2019/06/2018.Annual-Report.Final_.pdf at 4 (47,817 calls for service in 2018); https://whitebirdclinic.org/wp-content/uploads/2020/07/CAHOOTS-Media.pdf at 1, 5 (Eugene and Springfield department budgets are $90 million, CAHOOTS budget is $2.1 million, CAHOOTS responded to “over 24,000” calls for service, $8.5 million saved in public safety spending, $14 million saved in emergency medical systems costs).

150 See https://assets.austintexas.gov/budget/19-20/downloads/2020_Approved_Budget.pdf at 338 (police budget pays for officers to be “dispatched to over 330,000 . . . calls and work an additional 260,000 self-initiated calls . . .”); http://www.austintexas.gov/edims/document.cfm?id=303933 at 18–20 (detailing the EMCOT program for the 2017 fiscal year).

151 See https://dashboard.edmonton.ca/dataset/EPS-Dispatch-Call-Volume/nwr3-uqyk (175,547 dispatches between Q4 2018-Q3 2019); https://www.edmonton.ca/city_government/documents/2016_-

_2018_OPERATING_BUDGET.pdf at 596 (annual spending of $1 million per year on 24/7 program); https:/

/www.edmonton.ca/city_government/documents/APPROVED_2019-2022_OPERATING_BUDGET.pdf at 560, 650 ($451,725,000 spent on police in 2019, an additional $875,000 for FY 2019 for 24/7 program); https://

reachedmonton.ca/wp-content/uploads/2020/06/2019_REACH_Annual_Report_Single.pdf at 2 (24/7 program responded to 13,955 events in 2019);, https://reachedmonton.ca/wp-content/uploads/2020/05/2020-REACH-Business-Plan_FINAL.pdf at 2 ($1.91 Social Return on Investment).

152 See (50,595 calls for service);at 130 (2018 actual spending); https://olympiawa.opengov.com/transparency#/19567/accountType=expenses&embed=n&breakdown=14252966-76e1-4781-9193-52ebee383049&currentYearAmount=cumulative&currentYearPeriod=years&graph=bar&legendSort=alpha&proration=true&saved_view=null&selection=ADE101C7A384A6F4376651C99F19F8E7&projections=null&projectionType=null&highlighting=null&highlightingVariance=null&year=2019&selectedDataSetIndex=null&fiscal_start=2019&fiscal_end=latest (2019 budget visualization, $773,888 spent on CRU); ($110,000 in startup costs); https://www.q13fox.com/news/behavior-health-teams-roam-olympia-offering-help-services (700 responses in first two months).

153 https://issuu.com/reachedmonton/docs/reach_annualreport_impact2017_web_m at 4 (“209% increase in events from year 1 to year 2,” and year 2 total was 7,943).

154 https://issuu.com/reachedmonton/docs/reach_annualreport_impact2017_web_m at 7.

155 This funding began in 2012. See https://www.edmonton.ca/city_government/documents/PDF/Approved_2012_Operating_Budget-Revised.pdf at 18.

156 https://issuu.com/reachedmonton/docs/reach_annualreport_impact2017_web_m at 2.

157 https://issuu.com/reachedmonton/docs/reach_annualreport_impact2017_web_m at 7.

158 https://issuu.com/reachedmonton/docs/2017_annual_report.

159

160 https://reachedmonton.ca/wp-content/uploads/2020/06/2019_REACH_Annual_Report_Single.pdf at

2.

161 https://www.edmonton.ca/city_government/documents/APPROVED_2019-2022_OPERATING_BUDGET.pdf at 49 (increased by $875,000).

162 Jack Moran, “Second ‘Intervention’ Van Funded, The Register Guard (Mar. 4, 2011) (in 2011, contract “doubled” to $566,000).

163 Id.

164

165 Jack Moran, “Second ‘Intervention’ Van Funded, The Register Guard (Mar. 4, 2011) (in 2011, contract “doubled” to $566,000).

166

167 Id.

168 https://www.eugene-or.gov/DocumentCenter/View/47955/In-Cahoots---How-the-unlikely-pairing-of-cops-and-hippies-became-a-national-model-Register-Guard---Oct-20-2019.

169

170 https://whitebirdclinic.org/wp-content/uploads/2020/07/CAHOOTS-Media.pdf at 3.

171

172 Id.

173 Id.

174 https://whitebirdclinic.org/wp-content/uploads/2020/07/CAHOOTS-Media.pdf at 3.

175

176 https://kval.com/news/local/cahoots-starts-24-hour-eugene-service-in-january-2017.

177 Id.

178 https://www.eugene-or.gov/DocumentCenter/View/47955/In-Cahoots---How-the-unlikely-pairing-of-cops-and-hippies-became-a-national-model-Register-Guard---Oct-20-2019.

179 Id.

180 https://www.cbsnews.com/news/mental-health-team-responds-to-emergencies-oregon-alternative-to-police-2019-10-23/.

181

182 https://www.eugene-or.gov/DocumentCenter/View/36289/FY18-Adopted-Budget at 41.

183 https://www.springfield-or.gov/wp-content/uploads/2019/01/FY19BudgetBook_002.pdf at 210.

184 https://www.eugene-or.gov/DocumentCenter/View/36289/FY18-Adopted-Budget at 41.

185

186 https://edition.cnn.com/2020/07/05/us/cahoots-replace-police-mental-health-trnd/index.html.

187 Id.

188 https://www.springfield-or.gov/wp-content/uploads/2019/01/FY19BudgetBook_002.pdf at 208.

189 https://www.springfield-or.gov/wp-content/uploads/2019/01/FY19BudgetBook_002.pdf at 210.

190 https://whitebirdclinic.org/wp-content/uploads/2020/07/CAHOOTS-Media.pdf at 1.

191 https://www.springfield-or.gov/wp-content/uploads/2019/07/FY20-Adopted-Budget.pdf at 204, 206.

192 https://www.eugene-or.gov/DocumentCenter/View/47638/FY20-Adopted-Budget at 3; https:/

/www.indybay.org/newsitems/2020/07/02/18834819.php.

193 https://www.census.gov/quickfacts/schenectadycitynewyork.

194 https://www.cityofschenectady.com/302/About-SPD.

195

https://www.cityofschenectady.com/307/History#:~:text=In%20the%20late%2…

%20change%20in%20police%20manpower.

196 http://www.cityofschenectady.com/DocumentCenter/View/2277/2019_Adopted_Budget.

197 https://www.census.gov/quickfacts/newrochellecitynewyork.

198 https://www.newrochelleny.com/DocumentCenter/View/11722/NRPD-Annual-Report-2018.

199 Id.

200 https://www.newrochelleny.com/DocumentCenter/View/11735/2020-Adopted-Budget.

201 Similar to Albany’s enlarged daytime downtown population, two shopping centers in Clarkstown “can double the population on any given weekend.” www.clarkstownpba.org.

202

203 https://town.clarkstown.ny.us/town_hall/police_department.

204

205

206

207 https://greenburghny.com/247/About-the-Department.

208 https://greenburghny.com/DocumentCenter/View/6344/2020-Town-Budget.

209

210 https://greeceny.gov/files/Final_Adopted_Budget.pdf.

211

212 http://www.amherst.ny.us/content/departments.php?dept_id=dept_16.

213 http://www.amherst.ny.us/pdf/comptroller/2020_adopted/191107_entire_adopted_budget.pdf.

214

215 http://www.ramapo.org/page/police-31.html.

216

http://www.ramapo.org/uploads/finance/1574797023_2020%20Adopted%20Budget%20Consolidated.pdf.

217 https://www.census.gov/quickfacts/syracusecitynewyork.

218 https://www.syracuse.com/news/2019/11/deal-with-police-union-would-require-new-city-cops-to-live-in-syracuse-for-5-years.html; https://spectrumlocalnews.com/nys/central-ny/news/2020/01/17/35-new-syracuse-police-officers.

219 http://www.syrgov.net/uploadedFiles/Departments/Budget/FY%202019-2020%20Adopted%20Budget.pdf.

220

http://www.syrgov.net/uploadedFiles/Departments/Budget/Content/Budget_Documents/Adopted%20Budget

%202018-2019.pdf.

221 http://www.syrgov.net/uploadedFiles/Departments/Budget/FY%202019-2020%20Adopted%20Budget.pdf.

222

223

224 https://www.urban.org/sites/default/files/publication/28626/412089-Strategies-for-Improving-Homeless-People-s-Access-to-Mainstream-Benefits-and-Services.PDF

Homeless-People-s-Access-to-Mainstream-Benefits-and-Services.PDF at 74, 213.

225 2020 Albany County Executive Budget,

https://www.albanycounty.com/home/showdocument?id=12728 at 159.