29 Aug
If crisis is preventable, data must act first. For patients facing housing instability, food insecurity, or transportation barriers, traditional clinical data doesn’t tell the full story. These social factors often signal risk long before an ED visit or crisis call. SAMHSA’s 2025 Guidelines and the Crisis Now model agree: the future of behavioural health hinges on real-time, proactive planning and data is the foundation.
To shift from reactive care to prevention, care teams need more than observations: they need connections across systems. FHIR makes this possible. Aigilx Health makes it practical.
Why Social Data Matters in Crisis Care
Clinical charts may capture diagnoses and meds, but not the eviction notice a patient received last week. That disconnect costs lives and drives up avoidable utilization.
The reality:
- People with unmet social needs are more vulnerable to behavioural health crises
- ED visits often occur after warning signs surface outside clinical settings
- Care teams need social and clinical signals in one view to act early
SAMHSA emphasizes SDOH screening and response as essential, not optional, for high-functioning crisis systems. When this information is visible and actionable, care shifts from stabilization to prevention.
The Crisis Now Model: A Blueprint for Coordination
Crisis Now sets the standard for 24/7 behavioural health response, built around three core elements:
- Someone to call (e.g., 988)
- Someone to respond (mobile crisis teams)
- A safe place to go (stabilization centers)
But just having these services isn’t enough. The model depends on real-time data integration:
- Social risk data must flow with the individual, from call center to care team
- Clinical insights must follow the patient through mobile and stabilization settings
- All actors -behavioural health providers, CCBHCs, MCOs, and community orgs – must operate from a shared understanding
Without integration, we are simply responding. With it, we can prevent.
The Role of Technology: SAMHSA’s Expectations, FHIR’s Answer
SAMHSA’s 2025 Guidelines make one thing clear: technology is not just supportive; it’s transformative. From care coordination to telehealth access, systems must evolve to operate faster, smarter, and more equitably. FHIR, with its modular structure and real-time exchange capabilities, is how behavioural health organizations meet that mandate.
Here’s how the five technology priorities in the Guidelines come to life through FHIR:
1. Coordinated Platforms
SAMHSA calls for central hubs that connect call centers, mobile teams, stabilization units, and community partners. FHIR powers that coordination.
- Use CarePlan to unify goals and interventions across settings
- Trigger mobile dispatch with Task linked to crisis Events
- Exchange referrals with social care via ServiceRequest, tracked with Task
2. Smart Data Collection
Real-time reporting is vital – but only if the data is standardized and meaningful.
- Capture housing, food, and transportation risks using Observation (Gravity-aligned)
- Store longitudinal needs as Condition
- Stream program insights via Bulk Data exports for dashboards and metrics
3. Telehealth and Hybrid Models
Access doesn’t stop at the clinic door. SAMHSA encourages tech-enabled flexibility.
- Document telehealth encounters with Encounter and Appointment
- Share care instructions and plans remotely via CarePlan and DocumentReference
4. Privacy and Security
Data exchange must be secure, consent-driven, and respectful of individual rights.
- Capture sharing preferences with Consent
- Log access events with AuditEvent
- Apply least-privilege access using FHIR’s role-based permissions
5. AI for Training and QA
SAMHSA supports AI in training and quality, not crisis response. FHIR supports the governance foundation.
- Use de-identified Encounter and Observation data to simulate training scenarios
- Log model outputs for QA review, tied to real-world outcomes via MeasureReport
Together, these patterns form a modern, SAMHSA-compliant architecture.
Use Case in Action: From Risk to Response
Let’s walk through a real-world example of FHIR-enabled, SAMHSA-aligned care:
- A behavioural health patient is screened for SDOH and flagged for eviction risk in a community system.
- That screening enters the EHR via FHIR as an Observation.
- The care team adds a housing goal to the CarePlan and places a referral via ServiceRequest to a local housing agency.
- The housing partner accepts the case, updates the Task as progress is made, and supports the patient’s stability.
- If a crisis escalates, the care team uses FHIR-linked data to route the patient to mobile crisis or stabilization services.
- Post-crisis follow-up is scheduled via telehealth, and all interactions are securely tracked with consent.
Results: Fewer emergency visits. Reduced crisis recurrence. Stronger, earlier engagement.
What This Means for Care Delivery Leaders
Patient-centered planning isn’t just about empathy—it’s about visibility. With FHIR-enabled data sharing, care teams can:
- Spot risks earlier and build crisis-resistant plans
- Coordinate housing, food, and transport support before ED reliance sets in
- Align with SAMHSA and Crisis Now expectations through structured, reportable workflows
- Meet technology maturity expectations without rebuilding from scratch
Who benefits:
- Behavioural health organizations looking to reduce avoidable utilization
- CCBHCs seeking seamless coordination across care settings
- Medicaid MCOs aiming to improve risk-adjusted outcomes and engagement
- Community-based organizations needing visibility and partnership in care planning
Where Aigilx Health Leads
At Aigilx Health, we specialize in enabling behavioural health organizations to operationalize the promise of FHIR and meet SAMHSA’s vision with precision and speed. Our solutions are purpose-built for crisis systems and community networks that need to respond in real time and act proactively.
Our care coordination platform supports integrated SDOH workflows, seamless referrals across partners, and real-time insights for care teams. Combined with our Enhanced FHIR Server, we provide the foundation for data liquidity, compliance, and measurable impact.
Whether you’re a CCBHC, Medicaid MCO, or part of a regional crisis network, Aigilx Health delivers the architecture, expertise, and execution to unify care around the patient: before, during, and after a crisis.
Let’s build smarter, integrated crisis systems – before the next episode begins!!
Source: SAMHSA 2025 National Guidelines; HL7 FHIR; Gravity Project; Crisis Now model
Aigilx health specializes in developing Interoperability solutions to create a healthcare ecosystem and aids in the delivery of efficient, patient-centric and population-focused healthcare.
