Re-imagining New York City's mental health emergency response

A core principle of B-HEARD is providing individuals with care and services in the community. B-HEARD helps people experiencing a mental health emergency quickly get appropriate help in the community or in their home. Community-based support is individualized to the person. It can include new and re-connections to existing outpatient care, referrals to mobile outreach teams, or providing community-based resources.

By connecting individuals to care beyond a hospital emergency department, New York City has helped more New Yorkers in crisis get support wherever they are located. This ensures that those transported to a hospital genuinely need further evaluation or a level of care not available in the community. Importantly, the goal of the B-HEARD program is not to eliminate transports to the hospital, but to reduce unnecessary transport.

When transport to the hospital emergency room does occur, the individual has the trauma-informed support of the B-HEARD team, which can lead to an easier transition into care. This can include relaying clinical information to the hospital staff, accompanying the individual to the emergency department and/or communicating with family and providers about the plan for evaluation at a hospital.

In New York City, 911 remains the primary way that New Yorkers call for help during an emergency – including mental health emergencies. Further, about 88% of the 911 calls reporting a mental health emergency are observers describing what they are seeing, instead of the actual individual who is experiencing the mental health emergency. Speaking to a caller who is not the individual in distress can make it challenging to gather clear information about what is occurring. Added to that, the very nature of emergencies is fluid, dynamic, and quickly evolving even while the operator is speaking with the caller.  This is especially true of 911 mental health calls.   

While this chart displays the total number of 911 mental health calls, not all mental health calls are eligible for a B-HEARD response.    

Part of the process of deploying a B-HEARD team is ensuring that the call is appropriate for a B-HEARD response, which means that there is no known violence or weapons related to the 911 call and that information provided on the 911 call does not indicate need for immediate transportation to the hospital. 

The complexity of 911 calls has a direct impact on how many calls are eligible for B-HEARD dispatch.  Dispatching appropriate 911 mental health calls to B-HEARD teams involves coordinating between two different systems namely, the NYPD 911 operators and the FDNY EMS 911 operators. Mental health crisis calls are first categorized by NYPD operators. Mental health crisis calls are then transferred to FDNY EMS 911 operators for further triaging. Based on the EMS triage and/or the NYPD categorization, calls that include violence, weapons, or imminent risk of harm receive an NYPD response. 

EMS 911 call takers ask a series of questions to further assess for violence, weapons, and need for immediate transportation to the hospital. This is how 911 mental health calls are determined to be eligible or not for a B-HEARD response.  

Not all mental health emergency calls are eligible for a B-HEARD response. Typically, B-HEARD teams do not respond to calls involving individuals who require immediate transport to a hospital, present a risk of imminent harm to themselves or others, or get deployed in situations where EMS call-takers do not have enough information to assess the risk of imminent harm.  

Additionally, B-HEARD teams are not deployed to all eligible calls, and in these cases the traditional response of NYPD and EMS is deployed. This is typically because the B-HEARD teams were unavailable, responding to another call. The total number of calls responded to by B-HEARD teams does not include the number of times B-HEARD teams responded to requests from agency partners in the field, including NYPD and EMS. 

B-HEARD teams respond to mental health 911 calls independent from the NYPD’s decision to dispatch law enforcement. NYPD is informed of whether a B-HEARD team is dispatched to a call and NYPD responds if the team is not available within a certain amount of time. NYPD responds to calls when there is increased risk of harm, including situations on subway tracks, situations involving weapons, imminent harm (as identified by 911 caller), crime in progress, or other circumstances requiring law enforcement assistance. Once a B-HEARD team has arrived at a location, they can request backup from the NYPD if it is not safe for the B-HEARD team to intervene. A B-HEARD team can also be requested by NYPD, allowing the officers to move on to other matters.

During the first three years of operation, the best way to calculate B-HEARD’s response rate was to look at the number and percentage of eligible calls that received a B-HEARD response. While the percentage of eligible mental health 911 calls only increased from 31% in FY22 to 40% in FY24, the actual number of eligible calls increased significantly from about 3,400 to over 20,000. This significant increase is attributable to the program’s steady expansion to additional high needs communities during this time.    

Each B-HEARD response reflects the City’s historic commitment to providing people experiencing a mental health crisis with the most appropriate care by pairing mental health clinicians with EMTs.  Each encounter with a B-HEARD team means the City is providing a more appropriate response and better care to an individual experiencing a mental health crisis.  

Generally, once on scene, B-HEARD teams conduct physical and behavioral health assessments and provide on-site assistance, including but not limited to connecting the person to their existing medical and/or mental health provider, crisis counseling, or, with their consent, connecting them to follow-up services.

In FY24, about 50% of all B-HEARD responses or 7,417 B-HEARD patients engaged with a B-HEARD team. The total number of patient contacts is calculated by counting each instance in which a B-HEARD team treats a patient as a result of responding to a 911 mental health call that is made within the B-HEARD pilot area during the pilot’s hours of operation. Of those instances where the B-HEARD teams made contact with a patient as a result of responding to the call, in FY24, about 50% or 3,691 B-HEARD patients received a behavioral health assessment.  Generally, a B-HEARD response might not include a behavioral health assessment if the patient has an urgent medical need.

If a B-HEARD patient does not receive a behavioral health assessment, it is still beneficial to have a Mental Health Clinician present on scene, providing assistance and engaging the individual from a person-centered, recovery oriented, trauma-informed perspective. 

The Mental Health Clinician participates in the emergency response, as part of the B-HEARD Team for all calls and offers engagement, de-escalation and support.

If the person requires emergency medical services, teams provide emergency medical care and call EMS for an ambulance transport.

If emergency medical services are required or it is determined that transporting the patient to a hospital for a more comprehensive assessment is best, the B-HEARD team providing emergency medical care will arrange for an ambulance transport. In such cases, the presence of a Mental Health Clinician who can provide a warm hand-off once the person arrives to the hospital, enhances the experience for the person in crisis.

For almost a year, B-HEARD teams were dispatched to a broader range of mental health calls, including calls that may not have been fully screened and triaged by Emergency Medical Dispatch.  While this resulted in higher overall call volume for B-HEARD teams, there was also a higher number of instances where the call was not appropriate for B-HEARD response primarily due to a medical issue requiring a higher level of care, safety concern, or the person was no longer on scene in need of assistance.

Generally, it is not uncommon for a person to no longer be on scene or in need of assistance when a traditional response unit or B-HEARD team responds to a 911 mental health call for an array of reasons.   That said, we found that calls that have been fully triaged by call takers are more likely to result in the person still being on the scene when the team arrives versus calls that have not been triaged but still received a B-HEARD response.  Therefore, starting in June 2024, the city re-prioritized deploying B-HEARD teams to calls that have been fully triaged by EMS 911 call-takers to maximize the time B-HEARD teams spend serving patients.

Coupled with prioritizing B-HEARD teams responding to fully triaged calls, the city switched from using police precincts as geographic boundaries within the existing pilot area to flexible ones that are more aligned with how EMS units are dispatched. This program modification allows existing teams to be more adaptable in their ability to respond to nearby calls outside a precinct boundary once they have completed a call, which will increase their ability to respond to more calls.  

These two new strategies build on previous modifications to strengthen operations over the last three years.  Since launching B-HEARD in 2021, our approach has always been to learn as much as possible to inform how we optimize a health-centered emergency crisis response model that best meets the unique needs of our city. 

Accordingly, we have implemented modifications to strengthen operations over the last three years. For example, FDNY EMS developed, refined, and automated an algorithm for call takers use when they collect information on whether the individual has already been assessed by a mental health clinician. This algorithm helps inform the type of emergency response that is dispatched. FDNY has also hired more EMS 911 call-takers in Fiscal Year 2024 and NYC Health + Hospitals has conducted a B-HEARD patient experience survey that showed overwhelmingly positive feedback.