How alternative destination programs work—and what they mean for California’s behavioral health system
When someone in California experiences a behavioral health crisis, help usually comes through a 911 call, where they get sent to an emergency department.
But not everyone experiencing a mental health or substance use crisis needs to go to the ER. Emergency rooms aren’t environments built for people in psychiatric distress: they are loud, chaotic, and stressful.
That’s where alternative destination programs come in. These models give first responders the option to take people in crisis directly to sobering centers, crisis stabilization units, or psychiatric health facilities — environments specifically designed to provide the proper care, at the right time.
The goal is simple: to reduce unnecessary, traumatic, and expensive ER visits while connecting people to treatment that meets their needs.
What is an “Alternative Destination”?
An alternative destination is any licensed or certified facility equipped to receive individuals in behavioral health or substance use crisis when they don’t need emergency department services. Common examples include:
- Sobering Centers: Non-correctional facilities staffed around the clock, often by registered nurses, that offer safe environments for intoxicated people to become sober. They may be federally qualified health centers, state-certified outpatient detox providers, or accredited sobering centers.
- Authorized Mental Health Facilities: Licensed psychiatric hospitals, psychiatric health facilities, or certified crisis stabilization units with 24-hour clinical staffing.
- Crisis Stabilization Units (CSUs): Short-term facilities where people can be evaluated and stabilized by mental health professionals before connecting to ongoing care, typically for 23 hours.
These destinations are designed to meet individuals where they are — prioritizing safety, stabilization, and dignity over unnecessary hospitalization.
How California’s Triage to Alternate Destinations Program works
California’s emergency response system is overseen by the Emergency Medical Services Authority (EMSA), which establishes statewide standards for delivering emergency care. Each county or region operates its own Local Emergency Medical Services Agency (LEMSA), which is responsible for implementing these standards and tailoring protocols to local needs.
In 2014, the Office of Statewide Health Planning and Development (OSHPD) approved a Health Workforce Pilot Project (HWPP), which allowed EMSA to test the effectiveness and safety of Community Paramedicine and Triage to Alternate Destination (CP/TAD) models across specific jurisdictions.
In 2020, Assembly Bill 1544 (the Community Paramedicine or Triage to Alternate Destination Act) formally authorized LEMSAs to develop and operate these programs within their jurisdictions. In 2023, they extended the program through 2031.
How does the Triage to Alternative Destinations Program work in California? Local jurisdictions train their paramedics on how to assess individuals in behavioral health or substance use crises to determine whether emergency medical care is needed. If not, patients can be transported to a crisis stabilization unit, psychiatric health facility, or sobering center — settings designed to provide evaluation, stabilization, and connection to ongoing treatment.
Behavioral health professionals at these sites assess and connect individuals to care, reducing strain on emergency departments and helping ambulances return to service faster.
However, participation remains limited. Each LEMSA must formally opt in and establish local protocols before implementing the program. As a result, only five of California’s 58 counties — Fresno, Sacramento, Los Angeles, San Francisco, and Stanislaus counties — are currently using the program.
Do alternative destination programs work?
In short, yes. An independent evaluation from the University of San Francisco (UCSF) found these programs to be safe and effective means to improve health and safety. The evaluation found that 98% of patients transported to a mental health crisis center were effectively treated for their behavioral health needs.
The evaluation also found that ambulance patient offload times were considerably lower for transports to mental health crisis facilities and sobering centers than for transports to the ER, meaning that ambulances can respond to other 911 calls faster with these programs.
The evaluation highlighted the key benefits and challenges of alternative destination programs:
Benefits of alternative destination programs
- Reduced ER overcrowding: Behavioral health crises account for a significant share of emergency department visits, many of which could be handled elsewhere.
- Better patient outcomes: People in crisis are connected faster to the care they need, avoiding retraumatization and unnecessary holds.
- Cost efficiency: Alternative destinations use resources more effectively, saving hospitals, counties, and the state money.
- Workforce alignment: They make better use of paramedic skills and build bridges between emergency response and behavioral health systems
Challenges with alternative destination programs
- Regulatory restrictions: California is the only state in the nation where law still restricts paramedics from transporting patients to alternative destinations without special authorization.
- Training and workforce: There is no statewide training program for paramedics in behavioral health crisis response; each county must design and fund its own.
- Infrastructure and capacity: Many regions, particularly rural areas, lack available crisis stabilization or sobering beds.
- Insurance and reimbursement: Payment models often don’t cover transport to facilities that deliver this type of care, disincentivizing providers
Conclusion
California’s pilot projects demonstrate that alternative destination programs can improve outcomes, reduce emergency department strain, and improve system efficiency.
Expanding and standardizing these models would allow more communities to respond to behavioral health crises with the same urgency and compassion as medical emergencies — building a more coordinated, effective, and humane crisis response system statewide.
Our TakeThe Triage to Alternate Destinations pilot proved what advocates have long known: these programs work. They save lives, improve care, and ease pressure on overburdened hospitals and first responders. But California’s program isn’t permanent—it’s set to expire in 2031. On top of that, the barriers placed on counties to implement the program prevent counties from opting in. If we’re serious about creating a behavioral health system that treats mental illness and addiction as health issues, not emergencies, we need statewide policy that supports and funds these models, while addressing the real barriers that exist based on how the current statute is written. Every county should have the tools to build a health response to a health crisis. |