National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit

Knowledge Informing Transformation

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National Guidelines for Behavioral Health Crisis Care

Best Practice Toolkit Executive Summary
National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit

Knowledge Informing Transformation

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The National Guidelines for Crisis Care – A Best Practice Toolkit advances national guidelines in 

crisis care within a toolkit that supports program design, development, implementation and 

continuous quality improvement efforts. It is intended to help mental health authorities, agency 

administrators, service providers, state and local leaders think through and develop the structure 

of crisis systems. The toolkit includes distinct sections for: 

 Defining national guidelines in crisis care;

 Implementing care that aligns with national guidelines; and

 Evaluating alignment of systems to national guidelines.

Given the ever-expanding inclusion of the term “crisis” by entities describing service offerings 

that do not truly function as no-wrong-door safety net services, we start by defining what crisis 

services are and what they are not. Crisis services are for anyone, anywhere and anytime. Crisis 

services include (1) crisis lines accepting all calls and dispatching support based on the assessed 

need of the caller, (2) mobile crisis teams dispatched to wherever the need is in the community

(not hospital emergency departments) and (3) crisis receiving and stabilization facilities that 

serve everyone that comes through their doors from all referral sources. These services are for 

anyone, anywhere and anytime.

With non-existent or inadequate crisis care, costs escalate due to an overdependence on 

restrictive, longer-term hospital stays, hospital readmissions, overuse of law enforcement and 

human tragediesthat result from a lack of access to care. Extremely valuable psychiatric inpatient 

assets are over-burdened with referrals that might be best-supported with less intrusive, less 

expensive services and supports. In too many communities, the “crisis system” has been 

unofficially handed over to law enforcement;sometimes with devastating outcomes. The current 

approach to crisis care is patchwork and delivers minimal treatment for some people while 

others, often those who have not been engaged in care, fall through the cracks; resulting in 

multiple hospital readmissions, life in the criminal justice system, homelessness, early death and 

even suicide. 

A comprehensive and integrated crisis network is the first line of defense in preventing tragedies 

of public and patient safety, civil rights, extraordinary and unacceptable loss of lives, and the 

waste of resources. There is a better way. Effective crisis care that saves lives and dollars requires 

a systemic approach. This toolkit will delineate how to estimate the crisis system resource needs 

of a community, the number of individuals who can be served within the system, the cost of crisis 

services, the workforce demands of implementing crisis care and the community-changing 

impact that can be seen when services are delivered in a manner that aligns with this Best 

Practice Toolkit. Readers will also learn how this approach harnesses data and technology, draws 

on the expertise of those with lived experience, and incorporates evidence-based suicide 

prevention practices. 
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Core Services and Best Practices

The following represent the National Guidelines for Crisis Care essential elements within a nowrong-door integrated crisis system:

1. Regional Crisis Call Center: Regional 24/7 clinically staffed hub/crisis call center that provides 

crisis intervention capabilities (telephonic, text and chat). Such a service should meet

National Suicide Prevention Lifeline (NSPL) standards for risk assessment and engagement of 

individuals at imminent risk of suicide and offer quality coordination of crisis care in real-time;

2. Crisis Mobile Team Response: Mobile crisis teams available to reach any person in the service 

area in his or her home, workplace, or any other community-based location of the individual 

in crisis in a timely manner; and

3. Crisis Receiving and Stabilization Facilities: Crisis stabilization facilities providing short-term 

(under 24 hours) observation and crisis stabilization services to all referrals in a home-like, 

non-hospital environment.

In addition to the essential structural or programmatic elements of a crisis system, the following

list of essential qualities must be “baked into” comprehensive crisis systems: 

1. Addressing recovery needs, significant use of peers, and trauma-informed care; 

2. “Suicide safer” care; 

3. Safety and security for staff and those in crisis; and

4. Law enforcement and emergency medical services collaboration. 

Regional Crisis Call Hub Services – Someone To Talk To

Regional, 24/7, clinically staffed call hub/crisis call centers provide telephonic crisis intervention 

services to all callers, meet National Suicide Prevention Lifeline (NSPL) operational standards 

regarding suicide risk assessment and engagement and offer quality coordination of crisis care in

real-time. Ideally, these programs will also offer text and chat options to better engage entire 

communities in care. Mental health, substance use and suicide prevention lines must be 

equipped to take all calls with expertise in delivering telephonic intervention services, triaging 

the call to assess for additional needs and coordinating connections to additional support based 

on the assessment of the team and the preferences of the caller.

Minimum Expectations to Operate a Regional Crisis Call Service 

1. Operate every moment of every day (24/7/365); 

2. Be staffed with clinicians overseeing clinical triage and other trained team members to 

respond to all calls received;

3. Answer every call or coordinate overflow coverage with a resource that also meets all of 

the minimum crisis call center expectations defined in this toolkit;

4. Assess risk of suicide in a manner that meets NSPL standards and danger to others within 

each call; 
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5. Coordinate connections to crisis mobile team services in the region; and

6. Connect individuals to facility-based care through warm hand-offs and coordination of 

transportation as needed.

Best Practices to Operate Regional Crisis Call Center 

To fully align with best practice guidelines, centers must meet the minimum expectations and:

1. Incorporate Caller ID functioning;

2. Implement GPS-enabled technology in collaboration with partner crisis mobile teams to 

more efficiently dispatch care to those in need;

3. Utilize real-time regional bed registry technology to support efficient connection to 

needed resources; and

4. Schedule outpatient follow-up appointments in a manner synonymous with a warm 

handoff to support connection to ongoing care following a crisis episode.

To align with National Suicide Prevention Lifeline (NSPL) operational standards, centers must: 

1. Practice active engagement with callers and make efforts to establish sufficient rapport 

so as to promote the caller’s collaboration in securing his/her own safety; 

2. Use the least invasive intervention and consider involuntary emergency interventions as 

a last resort, except for in circumstances as described below; 

3. Initiate life-saving services for attempts in progress – in accordance with guidelines that 

do not require the individual’s consent to initiate medically necessary rescue services; 

4. Initiate active rescue to secure the immediate safety of the individual at risk if the caller 

remains unwilling and/or unable to take action to prevent his/her suicide and remains at 

imminent risk; 

5. Practice active engagement with persons calling on behalf of someone else (“third-party 

callers”) towards determining the least invasive, most collaborative actions to best ensure 

the safety of the person at risk;

6. Have supervisory staff available during all hours of operations for timely consultation in 

determining the most appropriate intervention for any individual who may be at 

imminent risk of suicide; and

7. Maintain caller ID or other method of identifying the caller’s location that is readily 

accessible to staff. 

True regional crisis call center hub services that offer air traffic control-type functioning are

essential to the success of a crisis system. Cracks within a system of care widen when individuals 

experience interminable delays in access to services which are often based on an absence of:

1. Real-time coordination of crisis and outgoing services; and

2. Linked, flexible services specific to crisis response; namely mobile crisis teams and crisis 

stabilization facilities.
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Mobile Crisis Team Services – Someone To Respond

Mobile crisis team services offering community-based intervention to individuals in need 

wherever they are; including at home, work, or anywhere else in the community where the 

person is experiencing a crisis. For safety and optimal engagement, two person teams should be 

put in place to support emergency department and justice system diversion. EMS services should 

be aware and partner as warranted.

Minimum Expectations to Operate a Mobile Crisis Team Services 

1. Include a licensed and/or credentialed clinician capable to assessing the needs of 

individuals within the region of operation; 

2. Respond where the person is (home, work, park, etc.) and not restrict services to select 

locations within the region or particular days/times; and

3. Connect to facility-based care as needed through warm hand-offs and coordinating 

transportation when and only if situations warrants transition to other locations.

Best Practices to Operate Mobile Crisis Team Services 

To fully align with best practice guidelines, teams must meet the minimum expectations and:

1. Incorporate peers within the mobile crisis team; 

2. Respond without law enforcement accompaniment unless special circumstances warrant 

inclusion in order to support true justice system diversion;

3. Implement real-time GPS technology in partnership with the region’s crisis call center hub 

to support efficient connection to needed resources and tracking of engagement; and 

4. Schedule outpatient follow-up appointments in a manner synonymous with a warm 

handoff in order to support connection to ongoing care.

Essential functions of mobile crisis services include:

 Triage/screening, including explicit screening for suicidality; 

 Assessment; 

 De-escalation/resolution; 

 Peer support; 

 Coordination with medical and behavioral health services; and

 Crisis planning and follow-up. 

Crisis Receiving and Stabilization Services – A Place to Go 

Crisis receiving and stabilization services offer the community a no-wrong-door access to mental 

health and substance use care; operating much like a hospital emergency department that 

accepts all walk-ins, ambulance, fire and police drop-offs. The need to say yes to mental health 

crisis referrals, including working with persons of varying ages (as allowed by facility license) and 

clinical conditions (such as serious emotional disturbance, serious mental illness, intellectual and 

developmental disabilities), regardless of acuity, informs program staffing, physical space, 

structure and use of chairs or recliners in lieu of beds that offer far less capacity or flexibility 

within a given space. It is important to fund these facility-based programs so they can deliver on 
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the commitment of never rejecting a first responder or walk-in referral in order to realize actual 

emergency department and justice system diversion. If an individual’s condition is assessed to 

require medical attention in a hospital or referral to a dedicated withdrawal management (i.e., 

referred to more commonly and historically as detoxification) program, it is the responsibility of 

the crisis receiving and stabilization facility to make those arrangements and not shift that 

responsibility to the initial referral source (family, first responder or mobile team). Law 

enforcement is not expected to do the triage or assessment for the crisis system and it is 

important that those lines never become blurred. 

Minimum Expectations to Operate a Crisis Receiving and Stabilization Service 

1. Accept all referrals;

2. Not require medical clearance prior to admission but rather assessment and support for 

medical stability while in the program;

3. Design their services to address mental health and substance use crisis issues;

4. Employ the capacity to assess physical health needs and deliver care for most minor 

physical health challenges with an identified pathway in order to transfer the individual 

to more medically staffed services if needed;

5. Be staffed at all times (24/7/365) with a multidisciplinary team capable of meeting the 

needs of individuals experiencing all levels of crisis in the community; including:

a. Psychiatrists or psychiatric nurse practitioners (telehealth may be used)

b. Nurses

c. Licensed and/or credentialed clinicians capable of completing assessments in the 

region; and

d. Peers with lived experience similar to the experience of the population served. 

6. Offer walk-in and first responder drop-off options; 

7. Be structured in a manner that offers capacity to accept all referrals, understanding that 

facility capacity limitations may result in occasional exceptions when full, with a no 

rejection policy for first responders; 

8. Screen for suicide risk and complete comprehensive suicide risk assessments and 

planning when clinically indicated; and

9. Screen for violence risk and complete more comprehensive violence risk assessments and 

planning when clinically indicated.

Best Practices to Operate Crisis Receiving and Stabilization Services 

To fully align with best practice guidelines, centers must meet the minimum expectations and:

1. Function as a 24 hour or less crisis receiving and stabilization facility;

2. Offer a dedicated first responder drop-off area;

3. Incorporate some form of intensive support beds into a partner program (could be within 

the services’ own program or within another provider) to support flow for individuals who 

need additional support; 

4. Include beds within the real-time regional bed registry system operated by the crisis call 

center hub to support efficient connection to needed resources; and

5. Coordinate connection to ongoing care.
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The Role of the Psychiatrist/Psychiatric Nurse Practitioner

Psychiatrists and Psychiatric Nurse Practitioners serve as clinical leaders of the multi-disciplinary 

crisis team. Essential functions include ensuring clinical soundness of crisis services through 

evaluation of need, continued monitoring of care and crisis service discharge planning.

Essential Principles for Modern Crisis Care Systems

Best practice crisis care incorporates a set of core principles that must be systematically “baked 

in” to excellent crisis systems in addition to the core structural elements that are defined as 

essential for modern crisis systems. These essential principles and practices are: 

1. Addressing Recovery Needs,

2. Significant Role for Peers,

3. Trauma-Informed Care,

4. Zero Suicide/Suicide Safer Care,

5. Safety/Security for Staff and People in Crisis and

6. Crisis Response Partnerships with Law Enforcement, Dispatch, and Emergency Medical

Services.

Addressing Recovery Needs 

Crisis providers must address the recovery needs of individuals and families to move beyond their 

mental health and substance use challenges to lead happy, productive and connected lives each 

and every day. 

Implementation Guidance 

1. Commit to a no-force-first approach to quality improvement in care that is characterized by

engagement and collaboration.

2. Create engaging and supportive environments that are as free of barriers as possible. This

should include eliminating Plexiglas from crisis stabilization units and minimal barriers

between team members and those being served to support stronger connections.

3. Ensure team members engage individuals in the care process during a crisis. Communicate

clearly regarding all options clearly and offer materials regarding the process in writing in the

individual’s preferred language whenever possible.

4. Ask the individual served about their preferences and do what can be done to align actions to

those preferences.

5. Help ensure natural supports and personal attendants are also part of the planning team,

such as with youth and persons with intellectual and developmental disabilities.

6. Work to convert those with an involuntary commitment to voluntary so they are invested in

their own recovery.

Significant Role for Peers 

A transformative element of recovery-oriented care is to fully engage the experience, capabilities

and compassion of people who have experienced mental health crises. Including individuals with 

lived mental health and substance use disorder experience (peers) as core members of a crisis 
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National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit 

Knowledge Informing Transformation 

team supports engagement efforts through the unique power of bonding over common 

experiences while adding the benefits of the peer modeling that recovery is possible. 

Implementation Guidance 

1. Hire credentialed peers with lived experience that reflect the characteristics of the

community served as much as possible. Peers should be hired with attention to common

characteristics such as gender, race, primary language, ethnicity, religion, veteran status,

lived experiences and age.

2. Develop support and supervision that aligns with the needs of your program’s team

members.

3. Emphasize engagement as a fundamental pillar of care that includes peers as a vital part

of a crisis program’s service delivery system. This should include (1) integrating peers

within available crisis line operations, (2) having peers serve as one of two mobile team

members and (3) ensuring a peer is one of the first individuals to greet an individual

admitted to a crisis stabilization facility.

Trauma-Informed Care 

The great majority of individuals served in mental health and substance use services have 

experienced significant interpersonal trauma. Mental health crises and suicidality often are 

rooted in trauma. These crises are compounded when crisis care involves loss of freedom, noisy 

and crowded environments and/or the use of force. These situations can actually re-traumatize 

individuals at the worst possible time, leading to worsened symptoms and a genuine reluctance 

to seek help in the future. 

On the other hand, environments and treatment approaches that are safe and calm can facilitate 

healing. Thus, we find that trauma-informed care is an essential element of crisis treatment. In 

2014, SAMHSA set the following guiding principles for trauma-informed care: 

1. Safety;

2. Trustworthiness and transparency;

3. Peer support and mutual self-help;

4. Collaboration and mutuality;

5. Empowerment, voice and choice; and

6. Ensuring cultural, historical and gender considerations inform the care provided.

Trauma-informed systems of care ensure these practices are integrated into service delivery. 

Developing and maintaining a healthy environment of care also requires support for staff, who 

may have experienced trauma themselves. 

Implementation Guidance

1. Incorporate trauma-informed care training into each team member’s new employee

orientation with refreshers delivered as needed.

2. Apply assessment tools that evaluate the level of trauma experienced by the individuals

served by the crisis program and create action steps based on those assessments.
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Zero Suicide/Suicide Safer Care 

Two transformational commitments must be made by every crisis provider in the nation: (1) 

adoption of suicide prevention as a core responsibility, and (2) commitment to dramatic 

reductions in suicide among people under care. These changes were adopted and advanced in 

the revised National Strategy for Suicide Prevention (2012), specifically via a new Goal 8: 

“Promote suicide prevention as a core component of health care services” (p. 51). 

The following key elements of Zero Suicide or Suicide Safer Care are all applicable to crisis care: 

1. Leadership-driven, safety-oriented culture committed to dramatically reducing suicide

among people under care, that includes survivors of suicide attempts and suicide loss in

leadership and planning roles;

2. Developing a competent, confident, and caring workforce;

3. Systematically identifying and assessing suicide risk among people receiving care;

4. Ensuring every individual has a pathway to care that is both timely and adequate to meet

his or her needs and includes collaborative safety planning and a reduction in access to

lethal means;

5. Using effective, evidence-based treatments that directly target suicidal thoughts and

behaviors;

6. Providing continuous contact and support; especially after acute care; and

7. Applying a data-driven quality improvement approach to inform system changes that will

lead to improved patient outcomes and better care for those at risk.

Safety/Security for Staff and People in Crisis 

Safety for both individuals served and staff is a foundational element for all crisis service settings. 

Crisis settings are also on the front lines of assessing and managing suicidality and possibly violent 

thoughts or aggressive behaviors, issues with life and death consequences. While ensuring safety 

for people using crisis services is paramount, the safety for staff cannot be compromised. Keys 

to safety and security in crisis delivery settings include: 

 Evidence-based and trauma-informed crisis training for all staff;

 Role-specific staff training and appropriate staffing ratios to number of clients being

served;

 A non-institutional and welcoming physical space and environment for persons in crisis,

rather than Plexiglas “fishbowl” observation rooms and keypad-locked doors. This space

must also be anti-ligature sensitive and contain safe rooms for people for whom violence

may be imminent;

 Established policies and procedures emphasizing “no force first” prior to implementation

of safe physical restraint or seclusion procedures;

 Pre-established criteria for crisis system entry;

 Strong relationships with law enforcement and first responders; and

 Policies that include the roles of clinical staff (and law enforcement if needed) for

management of incidents of behavior that places others at risk.
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Providers must establish environments that are safe for those they serve as well as their own 

team members who are charged with delivering high quality crisis care that aligns with best 

practice guidelines. The keys to safety and security for home visits by mental health staff include: 

 No mental health crisis outreach worker will be required to conduct home visits alone.

 Employers will equip mental health workers who engage in home visits with a

communication device.

 Mental health workers dispatched on crisis outreach visits will have prompt access to any

information available on history of dangerousness or potential dangerousness of the

client they are visiting.

Implementation Guidance

1. Commit to a no-force-first approach to care.

2. Monitor, report and review all incidents of seclusion and restraint with the goal of minimizing

the use of these interventions.

3. Remember that barriers do not equal safety. The key to safety is engagement and

empowerment of the individual served while in crisis.

4. Offer enough space in the physical environment to meet the needs of the population served.

A lack of space can elevate anxiety for all.

5. Incorporate quiet spaces into your crisis facility for those who would benefit from time away

from the milieu of the main stabilization area.

6. Engage your team members and those you serve in discussions regarding how to enhance

safety within the crisis program.

Law Enforcement and Crisis Response—An Essential Partnership 

Law enforcement agencies have reported a significant increase in police contacts with people 

with mental illness in recent years. Some involvement with mental health crises is inevitable for 

police. Police officers may (1) provide support in potentially dangerous situations when the need 

is assessed or (2) make warm hand-offs into crisis care if they happen to be first to engage. 

In many communities across the United States, the absence of sufficient and well-integrated 

mental health crisis care has made local law enforcement the de facto mental health mobile crisis 

system. This is unacceptable and unsafe. The role of local law enforcement in addressing 

emergent public safety risk is essential and important. With good mental health crisis care in 

place, the care team can collaborate with law enforcement in a fashion that will improve both 

public safety and mental health outcomes. Unfortunately, well-intentioned law enforcement 

responders to a crisis call can escalate the situation solely based on the presence of police 

vehicles and armed officers that generate anxiety for far too many individuals in a crisis. 

Implementation Guidance 

1. Have local crisis providers actively participate in Crisis Intervention Team training or related

mental health crisis management training sessions.
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2. Incorporate regular meetings between law enforcement and crisis providers, including EMS

and dispatch, into the schedule so these partners can work to continuously improve their

practices.

3. Include training on crisis provider and law enforcement partnerships in the training for both

partner groups.

4. Share aggregate outcomes data such as numbers served, percentage stabilized and returned

to the community and connections to ongoing care.

Psychiatric Advance Directives

A psychiatric or mental health advance directive (PAD) is a legal tool that allows a person with 

mental illness to state their preferences for treatment in advance of a crisis. They can serve as a 

way to protect a person's autonomy and ability to self-direct care. Crisis providers are expected 

to always seek to understand and implement any existing PAD that has been developed by the 

individual during the evaluation phase and work to ensure the individual discharges from crisis 

care with an updated and accurate psychiatric advance directive whenever possible. PAD creates 

a path to express treatment preferences and identify a representative who is trusted and legally 

empowered to make healthcare decisions on medications, preferred facilities, and listings of 

visitors.

Funding Crisis Care

The full Crisis Services Best Practice Toolkit document contains specific strategies on how a 

community can fund each of the core crisis system elements in single and multiple-payer 

environments. Additionally, recommendations on service coding already being reimbursed by 

Medicaid in multiple states are made available; including the use of HCPCS code H2011 Crisis 

Intervention Service per 15 Minutes for mobile crisis services and S9484 Crisis Intervention Mental 

Health Services per Hour or S9485 Crisis Intervention Mental Health Services per Diem for crisis 

receiving and stabilization facility services.

Training and Supervision

Many members of the crisis services delivery team are licensed mental health and substance use 

professionals operating within the scope of their license and training with supervision delivered 

in a manner consistent with professional expectations of the licensing board. Licensed 

professionals are expected to strengthen their skills and knowledge through ongoing CEU and 

CME professional advancement opportunities focused on improving team members’ ability to 

deliver crisis care. 

Providers also incorporate non-licensed individuals within the service delivery team; creating the 

need for additional training and supervision to ensure services are delivered in a manner that 

advances positive outcomes for those engaged in care. Verification of skills and knowledge of 
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non-professional staff is essential to maintaining service delivery standards within a crisis 

program; including the incorporation of ongoing supervision with licensed professionals available 

on site at all times. Supervision and the verification of skills and knowledge shall include, but is 

not limited to, active engagement strategies, trauma-informed care, addressing recovery needs, 

suicide-safer care, community resources, psychiatric advance directives and role-specific tasks. 

Conclusion

Crisis services must be designed to serve anyone, anywhere and anytime. Communities that 

commit to this approach and dedicate resources to address the community need decrease 

psychiatric boarding in emergency departments and reduce the demands on the justice system. 

These two benefits translate into better care, better health outcomes and lower costs to the 

community. The National Guidelines for Crisis Care – A Best Practice Toolkit delivers a roadmap 

that can be used to truly make a positive impact to communities across the country.