Medical College of Wisconsin
Medical College of Wisconsin Medical College of Wisconsin
Physician Patient
Psychiatry and Behavioral Medicine

CA:tCH Safety Plans

Coalitions that Adopted

Chequamegon Accountable: the Community for Health (CA:tCH) - Ashland & Bayfield Counties

Strategy Type

Community-based & Resources/Access

Strategy Goal

Reduce the need for crisis intervention and improve behavioral health outcomes for individuals and partner organizations by creating participant safety plans that allow for information sharing and teaming among trained project partners.

Intended Population

The entire population of Ashland and Bayfield Counties (about 31,000 people).

Strategy Background

Northern Wisconsin, like many sparsely populated regions, faces issues of low access and connectivity to care. Behavioral health services in the region are provided by a community health clinic, a critical access hospital, county health and human services, tribal health centers, and a number of small and private providers. With only one hospital containing a behavioral health unit across a seven-county region, there are limited beds, and the system is often overwhelmed. When those beds are full, patients in a behavioral health crisis must be transported across state lines to receive appropriate care or are placed in emergency detentions, creating a significant financial and psychological burden.

To address these challenges and decrease the rate of future mental health crises, the Resilience Alignment Beekeepers, a backbone organizing group, created Chequamegon Accountable: the Community for Health, an Accountable Community for Health (ACH) that worked to refine crisis response interventions in the area. By fostering collaboration between partner organizations across sectors, the coalition developed a system for information sharing, through a three-pronged process that involved preliminary discussions by the ACH, consultation with legal teams with expertise in Health Insurance Portability and Accountability Act (HIPAA) compliance, and ultimately the creation of the CA:tCH Safety Plan and Release of Information (ROI) documents.

The safety plan is a patient-centered framework for coordination across partner organizations that aims to address the behavioral health needs of the community and improve responses to behavioral health crises through the use of a shared information portal. This portal works within HIPAA, allowing for release of information and sharing between agencies, such as law enforcement and healthcare organizations. The process allows these organizations to legally and ethically view information chosen by the participant to best help them during a crisis.

Safety plan information is created and approved by patients, and the plan is designed to elicit information that will help build trusting connections with first responders, such as the participants’ sources of support, methods the individuals themselves identify as helpful for de-escalating distress, and other helpful information for law enforcement in the case of an emergency detention.

By building on existing safety plans used by various health agencies and partnering with the state-designated information exchange platform, Wisconsin Statewide Health Information Network (WISHIN), the coalition has been able to leverage existing support for behavioral health solutions into a new, feasible plan with the potential for long-term systems change.

"The CA:tCH Safety Plan represents a shift in how information sharing and teaming is done between key community stakeholders. When used successfully, this strategy can help save hundreds of thousands – if not millions – of dollars by reducing the need for expensive hospitalizations.”

– Project Director Wendy Kloiber

Special Considerations

When planning to implement a strategy such as the creation of a CA:tCH Safety Plan, take two primary considerations into account:
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Size of Community
Northern Wisconsin is a rural, sparsely populated area, so a safety plan would need adaptation for scale.
Level of Complexity
Each organization participating in your community group will likely be different from those that participated in the CA:tCH program, having both different organizational structures and levels of complexity. When looking to build your coalition, pay particular attention to the organizations within your community, and how their internal functions may differ from those in a rural community.

Strategy: Develop an Accountable Community for Health

The first years of implementation should involve the most important aspect to the success of the strategy: holding hour-long monthly meetings to develop relationships alongside the working strategy. Include frontline staff and those in administrative capacities across community sectors, like healthcare and social services, in hour meetings to obtain input on the complex lives of patients and gain an awareness of an organization’s capacity to increase staff workloads. Rather than holding conversations over what each member can contribute, an ACH involves cultivating a space for sharing and listening, allowing partners to build trust, express unique viewpoints on issues they face, brainstorm solutions, and ultimately resolve those issues.

Tip: Relationship building is about creating a space where organizations can answer the questions, “What don’t you like about the current behavioral health crisis process?” and “What do you wish worked better?”
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Analyze Crisis Response Procedures

In the first six months of planning, take time with your group of community partners to gather insights from key stakeholders and leadership from member organizations involved in crisis response procedures to better understand how resources are used and constrained by the existing processes. These interviews reveal what various stakeholders want to improve or solve in those processes and lay the groundwork for creating solutions. This portion of the strategy will require the most time and effort in order for the plan to come to fruition.

Gather Lived Experience Perspectives
Including people with lived experiences in monthly meetings allows you to focus on the perspectives of those most impacted by crisis response procedures and identify solutions that create the least restrictive response from law enforcement when tending to a mental health crisis.
Conduct Systems Mapping
Systems mapping provides member organizations a visual look at the various parts to the crisis response system and shows how they are connected. To ensure the group has a shared understanding of the entire system, establish that all partners must contribute with the pieces of the crisis response system their organization is involved in and they see and hear about the other aspects as well.
Model Legal Scenarios and Solutions
Building out hypothetical models based on the needs identified in the interview process provides a vision of the effects various changes to the behavioral health patient process would cause. Working through these models will build comfort and trust between community partners, as it grows their capacity for understanding the issue and reinforces the idea that a legal challenge will not derail the strategy.

Note: This is an iterative process that will ultimately require leaders from each participating organization to make important decisions on the design of their behavioral health patient process.
Determine Safety Plan Information

While many organizations operate with unique safety plans for individuals with high behavioral health needs, these documents are often lengthy. You should determine what information – outside of protected health information – should be included in a safety plan and how that information can be stored while legally and ethically addressing the patient’s rights to confidentiality.

Safety Plan Template (PDF)
Sample Plan (PDF)

Chapter 51 of the Wisconsin Statutes restricts availability of protected health information. This information can only be released to parties producing proper authorization and authority. In all other cases a court order is required to access this information.

Strategy: Consider Legal and Ethical Factors

In order to develop a process for legal and ethical patient information sharing, consult a number of legal opinions from attorneys with patient and HIPAA expertise. To create a CA:tCH Safety Plan, you will need to identify solutions surrounding the release and publishing of patient information to a HIPAA-compliant database accessible by partner organizations. Having this expertise will aid in making community partners comfortable to participate in the safety plan framework.
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Understand Electronic Health Record Rules
You will need to gain an understanding of the legal topics that dictate the possibilities of your project, such as health privacy and crisis response. Electronic Health Record (EHR) sharing rules are strict, so consult with a legal expert to determine the requirements of a safety plan that differentiate it from an EHR.

A key insight from the Beekeepers' legal consultation was that personal data in a safety plan is actually owned by the participant - the person filling in that information. Therefore, they have the right do what they want with that information.

Understand Involuntary Commitment Laws
You must also research state law regarding the role of first responding law enforcement officers, ER doctors, and various professionals in the county in the event of involuntary commitment to a mental health facility in order to determine what aspects will require the involvement of lawyers to analyze and provide solutions for.
Consider Eventual Circumstances
Creating a safety plan framework that lays out the knowns and unknowns of future circumstances allows those participating in the plan to make informed health decisions and protects partner organizations from future legal action. In order to protect participating organizations from potential future legal implications, spend time evaluating current health plan policies that are as specific as possible, but also address potential future concerns. Further, given organizations may join the safety plan framework down the road, you should account for the eventuality of information being shared with more than just the partners established at the time of the plan’s signing.

Tip: This can include running tabletop game scenarios, where each member organization is asked what their “worst nightmare” is, then the hypothetical is played out in the group.
Coordinate Data Sharing Mechanism
Consulting with an information exchange platform allows for safety plans to be stored and accessed by partner institutions more effectively and efficiently. Every state has a designated non-profit system, such as WISHIN in Wisconsin, though they are not the only option. These systems require a high degree of compliance with trainings and their own Memorandum of Understanding (MOU).
Develop Partnership Agreement
Partnership agreements must be developed to provide a formal legal framework that ensures participating organizations are compliant in sharing participant information in a secure manner. This includes the MOU that outlines partner roles and responsibilities as well as a joinder agreement, which allows partners to use the WISHIN system.
Agency Trainings

Training on the CA:tCH Safety Plan framework and WISHIN portal must be conducted for all community partners in order to remain HIPAA compliant. Training on the framework also assists in creating a shared culture for the project, allowing staff from different agencies to interact. This training can be conducted in-person or virtually by members of the coalition, while WISHIN staff must conduct the WISHIN Portal training for participants.

WISHIN CA:tCH Portal Training (PDF)
Introduction to WISHIN (Youtube video)
WISHIN & CA:tCH Training Slides (PPTX)

Data Collection

Collecting usage data from WISHIN and partner agencies reduces the risk of the project veering off course by holding those involved accountable. Ensure that each data item being collected is legally agreed upon through the MOU. Some of the most important metrics to collect include:

  • Frequency of safety plan use and revisions through the WISHIN portal;
  • Number of crisis calls;
  • Hospital admissions;
  • Emergency detentions;
  • Transfer to long-term hospitalizations;
  • Readmissions within 30 days;
  • Incarcerations;
  • Diversions;
  • Post crisis referrals and engagement; and
  • Participant satisfaction

Each member trained represents an average investment of five hours per person. In total 690 hours were committed to training workgroup partner agencies over 2 years.

“Without meeting with those people, we really have no idea what their perspectives are and what they bring to the table. So that’s the most valuable gain from sitting down with the diverse group and getting information to trouble shoot and strategize.”

– Partner Agency Staff Member

Challenges and Tactics to Address Them

Navigating successful strategy implementation can be complex, and obstacles may arise that set your plan back.

List of Challenges & Tactics

From generating community partner buy-in to managing unforeseen roadblocks, the path forward is often uncertain and challenging. The following section includes common challenges faced when developing and implementing CA:tCH Safety Plans and tactics recommended by the Resilience Alignment Beekeepers to address them and pave the way for successful implementation.
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Creating Efficient Trainings
Spending the time and money to train staff members at partner agencies can become expensive. The longer a training is, the more resources are needed. When developing a training that fits your project area, streamline the process by including only the most important information and making the trainings easily accessible to staff.
Participation Hesitancy from Member Organizations
Certain member organizations may be apprehensive to participate in the workgroup because they do not have the workforce capacity to institute a safety plan. Additional outreach should be conducted to emphasize the importance of gaining the organization’s perspective on crisis assessment and response procedures. The more involved an organization is, the more benefits are revealed.
Legal Implications
The threat of legal action being taken against those participating in the safety plan framework is daunting. To address these concerns, work with a legal team to account for potential challenges through hypothetical scenarios and give partners’ legal counsel opportunities for input and approval.
Participant Privacy Concerns
Potential participants in the safety plans may be wary of sharing personal information with certain member agencies, such as law enforcement. Facilitators should walk participants through the range of stakeholders with access to their plans, explaining why it’s important each organization has access to the plans, and explaining that the decision is ultimately their choice.
Getting Accustomed to the System
Facilitators who are also healthcare clinicians are not accustomed to sharing community-based patient plans. Continued trainings are necessary to embed these processes in the partner institution.
Evolving Scope

Over the course of developing the safety plan framework, the scope and uses for safety plans may grow or change. This makes it important to remain flexible to the direction the project takes and the opportunities it reveals.

With every new day, a fresh opportunity presents itself for the CA:tCH Safety Plan to be useful. The more the Resilience Alignment Beekeepers explored, the more became apparent about uses for aging and disability, expanded work with the youth in schools, and much more.

Best Practices

Through the process of implementing their respective behavioral health strategies, each AHW-funded coalition recorded its lessons learned to streamline their strategy processes going forward. Tried-and-true best practices also enhance the likelihood of achieving desired outcomes. The following section includes an insightful list of learned best practices the Resilience Alignment Beekeepers recommend other organizations employ to steer their strategies toward successful implementation.
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Hold a Soft Launch
In the early stages of implementation, too much attention to the safety plan framework could overwhelm health systems with an influx of requests to build plans. The process of member organizations embedding the framework takes time, and holding a soft launch can reduce demand and allows for flaws in the system to be worked out.

Tip: Once a member organization lays a foundation for the framework, consider a marketing strategy that opens up the program to a wider audience.
Conduct Community Listening Sessions
It is crucial to be open to the input of community partners, taking into account the uses they see for the framework, and brainstorming how you can put that into action. Input from those with lived experience with the crisis response system are especially crucial. Incorporating their input in the development of the safety plan framework provides perspective on what information is most valuable for first responders and healthcare partners to know and why. Without taking these ideas into account and considering solutions, the strategy may not have as great of an impact as it could.
Continuous Improvement

To ensure the program is continuously improving, hold regular debrief meetings with participating organizations to identify the pros and cons of the strategy and develop improvements. Conducting feedback surveys allows you to collect qualitative information about the coalition-building and strategy development process, and identify themes that may require more attention as you look to strengthen the coalition.

Feedback Survey (PDF)

Embed the Safety Plans
Having program partners adopt the CA:tCH Plan as their internal safety plan offers the client the option to upload their plan in the WISHIN system to share with the wider community and become a CA:tCH participant. This also ensures that facilitators are comfortable and familiar with the plan and provides participants an opportunity to renew or reconsider participation every six months in accordance with county protocols.
Hold Booster Trainings
Offering booster trainings to those who request it is important to ensure facilitators have a complete understanding of the CA:tCH Safety Plan framework and information sharing system.

Note: Organizations that have embedded the CA:tCH Safety Plan as a template for their Emergency Care Plans have required less booster trainings.
Conduct New Partner Onboarding
For every new partner organization who joins the safety plan framework, conduct an onboarding process that involves signing the MOU with WISHIN and your organization, training on the WISHIN portal, and training on the safety plan framework.
Involve Law Enforcement
Involving law enforcement in the safety plan framework can facilitate a transition of the practices law enforcement use when responding to mental health and substance use calls. It also builds relationships between health organizations and law enforcement, creating a path for deeper discussions about the challenge of serving people with co-occurring substance use disorders and mental health concerns.

CA:tCH Statistics

Of the 97 CA:tCH plans made, 11% were made by participants under 18 years old and 24% were made by participants aged 55+. 

97
CA:tCH Plans made
138
trained facilitators, first responders, and project leads
8
participating agencies

Highlights/Select Work Product

CA:tCH Plan Facilitation

CA:tCH Plan Use and Follow-up

Using the WISHIN CA:tCH Portal

Using WISHIN Pulse

Introduction to HIPAA

WISHIN CA:tCH Portal Training/Practice