1. Introduction My Name is Mina Ghoreishi Mghoreishi@cmha-Edmonton.ab.ca
Help Lines Manager at Canadian Mental Health Association, Edmonton Region
Oversee operations on Help Lines (211 Edmonton and Edmonton Distress Line)
Nice to meet you

2. Title
An Integrated Crisis Response –A Partnership between 211 Edmonton and local community agencies to provide a 24 hour comprehensive coordinated response to at risk populations.

3. Overview of Presentation
Challenge
Journey
Partners/Work Flow
Success
Data Review
Gaps
Next Steps
-I’ll talk about the challenge-need for crisis diversion,
-Journey that led us to existing partnership
-talk about partners and current work flow
-share success
-Data Review
-Gaps
-Next steps

4. Edmonton Narrative
-Edmonton is located in province of Alberta in Western Canada and is the capital of Alberta. Alberta is one province east of British Columbia.
-Edmonton is above Idaho and Montana and has a border with Montana
-The city has a population of around 900,000, with surrounding around 1.1 million.
-Alberta is Canada's fifth-largest municipality.
-Edmonton is the most northern North American city with a metropolitan population over one million.
-Edmonton hosts a year-round festivals, reflected in the nickname "Canada's Festival City".[1]
It is home to North America's largest mall, West Edmonton Mall
Alberta is home to large-scale oil sands, so with the drop in oil price, there has been a downturn to economy accompanied by job losses.

5. The Challenge
18, 599 Edmonton Police Service Social Disorder calls in 2015.
24/7 Crisis Diversion frees up costly police and ambulance services to respond to emergency situations.
Give you a context for a need for crisis diversion service in the city:
-Current number of police social disorder calls in the city is: 18, 559 (Annual Policing Plan 2015).
-We believe that only a portion of these events are truly policing or medical issues-the remainder could be better dealt with human service organizations.
-This way, police and emergency services remain available for emergencies
-24/7 Crisis Diversion initiative frees up police and ambulances to respond to emergency situations, using tax dollars money more efficiently and also aligns clients with client services.
-Businesses and public have expectations that individuals who appear intoxicated, sleeping rough, or who have a mental health crisis in public are supported in DIGNIFIED WAYS.
-There was a need to streamline connecting vulnerable people with the services they need most such as basic needs, food, shelter etc. and engage them in more permanent programs
-We realize that Crisis diversion is not a need that can ever be completely fulfilled. In fact, present economic realities are expected to push more people into hard times and the community can expect to see an increase in demand for these services
-We know that diverting crisis is really only dealing with the symptoms of deeper vulnerabilities (e. childhood trauma, addictions, inadequate housing and income) that create the crisis for people in the first place

6. Why Crisis Diversion Rather than Prevention/ Treatment
↓ inappropriate calls to EPS and EMS saves $$ and builds time efficiencies
↑ alignment with key stakeholders
Leverage existing services to bridge gaps in service to Edmonton’s most vulnerable persons
-The case for investing in crisis diversion-Rather than prevention or treatment is that it becomes a channel to direct clients to the appropriate services and supports presently available resources in the city.
-Crisis diversion will ensure client safety by minimizing any possible dangers associated with a crisis to the individual or others involved.
-Increase alignment with key stakeholders: police, emergency services, agencies, business and government and to connect with vital collaborating initiatives in the community who are best equipped to address the complex needs of individuals such as Outreach programs, etc.…?

7. Reach Edmonton
Council for Safe Communities in Edmonton
REACH Edmonton In Consultation with Edmonton Medical Services, Edmonton Police Service, Health Services, High level stake holders and the public, developed:
Recommendation for 24/7 Crisis Diversion
REACH is a Non for Profit Organization that is Edmonton's Council for Safe Communities.
-Brief overview about REACH: …
Reach, In consultation with EPS, EMS, AHS, High level stakeholders and public came up with a recommendations for designing a 24/7 Service Delivery Model for High Needs Individuals and took on the responsibility of developing a comprehensive, coordinated response to at-risk populations who need access to services 24 hrs a day.

8. The Journey to 24/7 Crisis Diversion
-The existing 24/7 Crisis Diversion service in Edmonton is the evolution of a program that has been working effectively since April The 1st iteration of the program was called 24/7 MAP did amazing work and absolutely fulfilled the mandate of responding to vulnerable people 24/7. The issue with the program as it stood was capacity.
-The 1st iteration only involved one operating body (Bissel Centre) and attempted to house those they met in crisis but learned that individuals with complex need take a log time to house
Result: Dropped Crisis Calls
-Expanding the 24/7 MAP model to the level that was needed in the community would cost between $25 million and $50 million annually.
-On the other hand, re-aligning and re-integrating the prototype across multiple agencies was expected to only cost $1.2 million annually (5-10% of the cost)
This could be accomplished through a combination of information sharing through the use of technology (app) and engaging 211 Edmonton and aligning programs across multiple service providers.

9. 5 Design Specifications of Creating 24/7 Crisis Diversion
1. Reducing # of “ inappropriate” calls to emergency services
2. System Oriented: Encourages systemic response
3. Feasible: Is within reach of financial, technical and human capacity of current service system
4. Viable: Helps shape policies, regulations, resources, etc.
5. Sustainable/Adaptive
The second iteration of 24/7 Crisis Diversion was designed with 5 design specifications in mind:
2. System Oriented encourages a systemic response, rather than organizational response in the coordination of design, delivery of diversion services and creates the regulatory and funding environment to support these shifts
4. Viable: helps shape the policies, regulations, resources to support front line practices of service providers-Informs allocation of resources-feedback loop
5. Sustainable/Adaptive: Practice and policy framework are sustained but adapted over time in a constantly shifting environment.

10. Process in Creating 24/7 Crisis Diversion Service
Participatory
Broadly Resourced
Iterative
PDSA Cycle: Plan, Do, Study, Adapt
30 day cycle for working group, 90 day for Steering Committee
Evolutionary
Participatory: Seeks to co-design the 24/7 response knowing that everyone works with constraints and their own agency mandates
Broadly Resourced: Taps into REACH Edmonton budget, but also draws upon existing agency resources and eventually other funding
Iterative: Employs multiple iterations of prototyping: PDSA Practice, data driven
Evolutionary:
-Crisis diversion to start off in downtown area where there is still the greatest concentration of diversion activity and
-With the anticipation that it will expand over time
-Do :Active and on the ground work
-Study: Reviewing data, identifying areas for improvement and innovation
-Adapt: Changing the way we are doing things
-Plan: Move forward with a plan

11. 24/7 Crisis Diversion – Partners & Service Alignments
We couldn’t move the needle on crisis diversion or well being by relying on one organization alone. The entire service delivery system had to come together to work differently or better.
-Focus was to bring staff from each partner agency closer so they could experience work as part of a team effort and there would be as much consistency in service as possible.
-Relational abilities of teams when engaging with clients and the community -

12. 24/7 Crisis Diversion Objectives: Leveraging existing services
• Integrating innovative programs, services and strategies
• Evaluating and engaging multiple stakeholders
Primary outcomes:
Reducing inappropriate use of emergency services
Connect vulnerable individuals with resources equipped to address their needs
This 24/7 model was anchored by the objectives of:
All organizations, businesses and community members have a role in crisis diversion

13. 24/7 Crisis Diversion Success
1st Iteration: 24/7 MAP – 5581 contacts in 2 years
2nd Iteration: 24/7 Crisis Diversion – 3031 contacts in 6 months!
More than doubled capacity to Respond
Excited to share the success of our partnership so far with you:
1st Iteration: 24/7 MAP – 5581 crisis diversion events in 2 years
2nd Iteration: 24/7 Crisis Diversion – 3031 contacts in 6 months!
The program has more than doubled its capacity to responds by refocusing and prioritizing response to crisis situations, and by aligning with existing services.
**Collaboration has allowed the number to increase and to make a difference on the streets
**Initial objectiev that an improved scale of response is only possible through a multi-agency, integrated approach that leverages existing services is already happening!

14. 1. Assertive Outreach 2. Transportation 3. Warm Hand-Off
3 Main Practice areas of 24/7 Crisis Response and Guiding Principles:
1. Assertive Outreach
2. Transportation
3. Warm Hand-Off
Assertive Outreach:
-Assertive engagement with individuals that require support to address multiple barriers
- Building rapport with the individual to meet them where they’re at. Very much voluntary, non jugemental and non intrusive. Relationship based service that cares about people and is tolerant of what are often difficult behaviors.
-Priority on diverting emergency services and crisis situations with high risk factors:
Rapport and relationship building
Provision of some basic needs
Repeated contact with individuals
Client centered approach
Definition of “Crisis Diversion Practice” is evolving as we learn more from each case and by reviewing the data
2. Transportation: Placement in shelters, detox, and community services, often times part of the solution in moving the individual from an unsafe situation to safety.
3. Warm Hand-Off: Coordination of service to the appropriate service provider to deliver case management and ensure continuity of care
-Might include advocacy and navigation through various systems to address needs and barriers in a timely and often creative manner

15. 24/7 Crisis Diversion
• Responds to people in distress on the streets of Edmonton around-the-clock, 7 days a week, 365 days a year.
• Presently there is one team of 2 workers 24/7, with one backup team from 8 a.m. to 8 p.m.
On average the teams respond to events a month.
24/7 Crisis Diversion frees up police and ambulances to respond to emergency situations, using tax dollars more efficiently.
So two daytime teams, from two different agencies, and one overnight team.
# of events depends on the time of year, cold vs. moderate weather, special events etc…
events – this number is growing rapidly, and our program is growing to meet those needs and ensure we have the capacity for effective response. It is important to maintain the response rate low.
 Business Owners or anyone out in the community, can call (211) if they someone who needs help or if they need the help for themselves.

16. What Crisis Diversion Does
Responds to calls from EMS, EPS and 211 (public and community services) when someone on the street is:
• Likely to come to come to harm without intervention
• Experiencing a mental health or medical non- emergency crisis
Intoxicated or otherwise impaired
-24/7 CDT responds to calls from three dispatch centres: EMS, EPS, and 211.
-It works with people in crisis who don’t need an ambulance or police, but who do need immediate care and are likely to come to harm if they don’t get help.
They may be intoxicated, or experiencing a mental health crisis, or even not dressed for how cold it is outside.   
24/7 CDT creates connections with the people it responds to, asking the right questions, and figuring out what they need to be safe.

17. When Crisis Diversion Cannot Respond
If someone needs emergency medical attention
Incidents involving violence, weapons or a large crowd
Non-crisis transportation
Security services*
*This is a voluntary service provision; our participants need to be willing to engage with 24/7 Crisis Diversion workers
Respond to calls inside of buildings deemed unsafe
A primary outcome of our program is to divert inappropriate 911 calls, but we are not an emergency service. If someone needs immediate medical attention, or the situation is violent the 911 is the right call to make.
24/7 CDT is not a transportation service, not a taxi!. However, if transportation is part of the solution to make people safe, we will provide that response. Others may require a warm hand-off to connect them to the help they need.
It is not a substitute for existing security services. In fact, because the service is completely voluntary, they can only work with people who want to engage with 24/7 workers.
What 24/7 CDT can do is provide services to move people from unsafe situations to resources where they can get help for their immediate needs. Vulnerable community members are often hiding in office buildings, malls, apartment lobbies, etc because of inclement weather or other unsafe situations. They can work with people to get them somewhere more appropriate to meet their needs.

18. Examples of Appropriate Referrals
Late November in Edmonton -13F (-25C), mid 40’s female lying on sidewalk, communicating but displaying symptoms of significant intoxication (No signs of aggression, trauma, weapon)
Refer to 24/7 CDT

19. Examples of Appropriate Referrals
Male, fifties, observed intoxicated staggering down street
24/7 CDT Referral
If individual happens to carry a weapon (e.g. jagged glass bottle)
Referral to 911
Possible follow up: Police may refer to 24/7 CDT for follow up support

20. Examples of Appropriate Referrals
Male observed screaming in middle of street (non-aggressive towards anyone). Evidence of mental health issue
Referral to24/7 CDT

21. Examples of Appropriate Referrals
Two males and a female are sleeping rough in an alley behind a local business, open alcohol and needles on site.
Referral to 24/7 CDT
Possible follow up with Police once on scene if it is unsafe to intervene.

22. 24/7 Crisis Diversion Prioritization Guidelines
Handing out this sheet, so you could look at it more closely if you will.
-Guideline for 24/7 CDT response prioritization.
-5 different categories to determine priority: Demographics, Reason for Transport, Level of Intoxication, Mobility Issues, Location

23. 24/7 Crisis Diversion Client Flow
SAFE
24/7
Crisis Diversion
PUBLIC
-24/7 CDT receives referrals directly from the three triage systems: 211, police and emergency medical services. When a call is placed to 911 that is more appropriate for 24/7 Crisis Diversion, they refer to the Crisis Diversion Teams . If a person is not injured and non-violent, the more appropriate stream to connect to 24/7 CDT is calling 211.
In order to know which stream is most appropriate for a person, you will need to engage with them and get some information about what is going on for them, and what they need.

24. Crisis Diversion Client Flow
More detailed breakdown of Crisis Diversion Work flow:
Crisis Diversion Client Flow

25. Operating Partners • Hope Mission Boyle Street Community Services
211 Edmonton a program of Canadian Mental Health Association
Current existing three operating partners are: Hope Mission, Boyle Street, and 211, a program of CMHA_ER.

26. Operating Partners • 211 Edmonton
-This is 8 of us from the 211Team in Edmonton, out of a team of 30 staff in the Help Lines program at Canadian Mental Health Association-Edmonton Region
-This was 211 Day (Feb 11th) celebration with my daytime team members
-211 was a program of The Support Network until Nov 2nd, when TSN was integrated with CMHA-ER.
-211 Edmonton was first accredited in st 211 Centre in Western Canada, The first was in Ontario in Help Lines (211 & Distress Line ) is comprised of 27 staff front line staff including casual staff, two Team Leads and myself as Help Lines Manger.
-24/7 service to connect people to community resources-A great fit for the partnership to triage calls for 24/7 CDT!

27. 211’s Role Check into immediate safety, assess any risks
With 3rd party calls, coach caller to assess for safety and watch for vital signs.
Conduct a Need Assessment by checking into the situation and safety- (e.g .Weapons? Violence? psychological state, intoxicated?)
Collect Caller’s information and location
Triage Calls and dispatch appropriate 24/7 CDT Team based on situation, time of day and geographic area.
Is everyone safe right now? Assess any risks that come up. Are emergency medical or police services required? For 3rd Party Callers coach them through asking person at risk “are you ok?”, “do you need and ambulance?” If no response to questions check for breathing by looking for chest movement. If there are no clear signs of breathing 911 is the referral For all CDT calls where 911 is required transfer caller to 911 operator. (instructions below)
What is the situation? Are there any relevant medical conditions? Any criminal activity? Weapons / offender(s) still present? What is the psychological state of the individual? Sober / intoxicated? Conscious / unconscious / sleeping? Agitated / calm / aggressive?
Have there been any attempted interventions by emergency medical or police services? Is there any other information that a first responder would need to know?
Is the client by themselves or with others? If with others, will they require service as well? Brief physical description of the client? For example, person is wearing a red shirt.
Collect the caller's name, phone number, and the street address where assistance is required. This is so the Crisis Diversion Team can contact the caller and share the outcome with them or call for any details they may need when responding. (Provide service education around the reason it is helpful for us to collect their phone number if necessary. It is okay if the caller doesn’t want to share their phone number.)
6.    If possible, collect the first name, last name, and birth date of the client. This allows the team to know if the client is banned from shelters or drop-in centres.
7.    Instruct the caller to call 211 back if situation changes (i.e. escalation in violence that requires the police, etc.) or if the Person at Risk leaves the area so we can report back to CDT.
Place caller on hold and dial (8:00 AM to 8:00 PM) or (8:00 PM to 8:00 AM) and provide the information. DO NOT give those numbers out to anybody (i.e. 311, public, social workers, etc.).
Select the "caller request 24 / 7 MAP Team" special code if the caller asked for this service, even if a referral was made to emergency medical or police services instead. DO NOT use the special code if the caller did not ask for this service, even if we had to dispatch the Edmonton Crisis Diversion Team.
Log the referral on your call report! Taxonomy: homeless transportation programs.
CDT 911 Transfers: We are not warm transferring to 911, 911 operators need to hear everything directly from the caller.
1.    Let caller know this is a 911 referral and you will transfer them to provide the information they shared with the 911 operator.
2.    Do no put the caller on hold
3.    Press the , type 911 in the box
4.    Click transfer, this will disconnect the caller from you and transfer them to 911

28. Hope Mission
Not-for-profit Christian social care agency caring for impoverished and homeless men, women and children in Alberta.
The 24/7 Rescue Van, a converted ambulance, exists to provide basic human care to people living on the streets who may be in crisis, while also providing spiritual, emotional and social support.
The 24/7 Rescue Van responds to people experiencing non-emergency or non-violent crisis. We provide crisis diversion to help alleviate pressure of EMS and EPS response time. The 24/7 Rescue Van is available to care for people who are in a non-emergency crisis, which frees up EMS and EPS to respond to emergency situations.
The 24/7 Rescue Van responds to calls from EMS and EPS, as well as 211. We provide crisis intervention services for someone who might be experiencing a mental health crisis, when someone’s safety is at risk or if someone is intoxicated or otherwise impaired.
Our 24/7 Rescue Van drivers work around the clock to provide essential items, food, bottled water and support to vulnerable people. Our drivers build relationships with people living on the streets, getting to know them and connecting them with the appropriate resources and supports they need.

29. Boyle Street Community Services
Non-Profit Edmonton agency which assist individuals and families challenged by homelessness and poverty.
Boyle Street Community Services: Non-profit Edmonton agency which assists individuals and families challenged by homelessness and poverty.
-Runs a number of programs and service including harm reduction needle exchange program, housing outreach, and shelters.
The van is branded with CDT logos, branding is a work in progress. The partnership is working towards

30. Data Review April 2016-Referral Source
Data Review for month of April based on stats that crisis diversion front line teams document for every contact.
Majority of referrals have originated from 211 (~33%)
Police Service is in the second place with ~26%
And Medical Services with ~22%

31. Data Review-April 2016 Number of Contacts by Day of Week
Recent data indicate that Fridays and Saturdays tend to be busier days for 24/7 Crisis Diversion Calls.

32. Data Review-April 2016 Call Volume by Hour of Week
-Busiest Time of the day tend to be 7pm-12am, with a peak around 8pm.

33. Data Review (April 2016)-Precipitating Factors to Crisis
BSCS
Hope
Total
Percentage
Addictions 4
Disability 1
Domestic Abuse
0.2%
Homelessness 45
157
202
46.7%
Intoxication 59
149
208
48.0%
Mental Health/Addictions 6 5 11
2.5%
Physical Health 7 14
3.2%
Sexual Exploitation
0.0%
Other 3
0.9%
None Indicated 61 74
135
31.2%
-Intoxication and Homelessness have been identified as the top precipitating factors for crisis in April, but data is representative for previous months as well.
-Still a wide category for “None Indicated”, This is an area of growth where the requirement for data collection is becoming tighter and there is more ongoing consistent training for front line staff to capture the data as they provide the service.

34. Data Review-April 2016 Warm Handoffs
Outgoing Referrals
Total
Percentage
Addictions 3
1.3%
Basic Needs 11
4.7%
Disability
0.0%
Domestic Abuse Shelter
Drop-In Centre
Emergency Shelter
134
57.5%
EMS (Ambulance) 9
3.9%
EPS 10
4.3%
Finances 2
0.9%
Hospital 19
8.2%
Hotel
Legal
Medication 1
0.4%
Mental Health
Physical Health
Sexual Exploitation
Social/Recreational
Transport to Private Residence 4
1.7%
Other 35
15.0%
233
100.0%
Blank/None
204
437
Warm Handoffs or outgoing referrals:
Emergency Shelters makes up ~58% of outgoing referrals or warm handoffs.

35. Data Review-April 2016 - Client Demographic
Majority of clients are with most (17%) falling in category

36. Data Review-April 2016 - Client Demographic
Gender
Total
Percentage
Male
142
72.1%
Female 55
27.9%
197
100.0%
72% of clients are male and 28% female

37. Data Review-April 2016 - Client Demographics
Majority of clients are Aboriginal (~66%).
Edmonton has a large population of aboriginal people-second largest Aboriginal population of all cities in Canada-1st is Winnipeg with 68,380.
-Total population of aboriginal people is 52,105, which is around 5.8% of Edmonton’s population.

38. “They made me believe that people do care and are there to help me”
SROI Analysis
The investment in 24/7 Crisis Diversion shows a return of $2.23 in social value for every $1 invested.
Social Return of Investment: SROI
24/7 Crisis Worker hourly wage: $23-$25/hour whereas wage for police staff is significantly higher.
- Builds efficiency
“They made me believe that people do care and are there to help me”

39. Current Existing Gaps in Service
On site medical and mental health services
Intox shelter space, transitional detox and detox space
Immediate detox access and addiction support/treatment services
Affordable and permanent supportive housing with harm reduction practices
The 24/7 Crisis Diversion Initiative is in a very good position to identify gaps in existing community services for vulnerable individuals and is able to report the gap to funders and takeholders.
Here is a list of gaps in services currently identified in Edmonton:

40. Next STEPS Develop public awareness campaigns
Better defined crisis prioritization guidelines
Consistent specialized training for teams on specific topics :
such as cultural awareness,
high risk lifestyles
crisis intervention,
trauma informed etc..
Develop public awareness campaigns
agencies)
Address gaps, challenges
Public awareness campaigns to raise awareness about the services, and ALSO:
-build understanding of downtown community, treat all community members with respect
-Develop “hospitality” messaging with security to engage positively with all

41. Next STEPS Continued $ 1 Million Expansion Volume and Geography
2 more Teams
Expanded geographic areas and “hot spots” beyond downtown
Special event coverage
-> Patrol by foot
Trap Houses
Gang Activity
Community Engagement
Engage more community organizations (i.e. Government, Libraries, and businesses
Special Events: Patrol by foot to contribute to a friendly and safe atmosphere during events and have immediate access to any non-emergency crisis situations that may require referral to community or emergency services.
Trap Houses: These houses are rented by unknown adults with gang affiliations who disappear-youth are enticed to “party” at these locations and then become entrenched in various types of exploitation (sexual/drug dealing)
-These houses are eventually closed by EPS and then another one opens up shortly after.

42. Questions? Thank you for your time Mina Ghoreishi
-Canadian Mental Health Association-Edmonton
-Help Lines Manager