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Police call this mental health crisis program 'a godsend.' Could it work in Idaho?
Idaho Statesman - 12/9/2018
Dec. 09--LINCOLN, Nebraska -- Travis Parker in 2005 took the first-ever call to a special hotline.
Police were at a trailer home in rural Saline County, Nebraska. The woman living there was suicidal, and officers needed a hand. Parker was the on-call counselor that first day; he made sure the woman was safe, then signed her up with a case manager to get longer-term help.
The hotline was the Targeted Adult Service Coordination program out of Lincoln, Nebraska. Officers have since called it more than 1,800 times -- whenever they needed a professional to help them handle a mental health emergency.
About 82 percent of the time, counselors like Parker kept people in crisis from ending up on emergency mental holds. And they saved rural officers hours of time on the road to and from Lincoln, where such people would otherwise have had to go for crisis care.
It's a program that doesn't exist in Idaho, where police officers and sheriff's deputies may be the first and only people to respond to mental health emergencies in rural areas. That costs those departments time and requires extra training for their employees. And, the number of people fatally shot by Idaho law enforcement has spiked this year; many of the confrontations appeared to involve mental illness.
One Idaho lawmaker says Nebraska's model sounds like a great idea. But whether the Legislature would pay for it is the question, he says -- especially while lawmakers are trying to figure out how to pay for Medicaid expansion.
This social worker goes where her clients are -- even out behind a gas station.
How does TASC help clients?
TASC has licensed mental health providers on call every hour of every day. The law enforcement agencies that use it cover Lincoln and the surrounding rural areas, and range in size from one officer to dozens.
"It's been a godsend for us," said Nebraska City Police Chief Dave Lacy.
Before TASC, "if things went real smooth, maybe an officer would be back in 2 1/2 hours," Lacy said. "Sometimes three, sometimes four. So we were losing manpower on the street -- and I guess that's not a big deal if we had 10 or 15 guys working a day. But we don't. We have three to four."
The crisis counselors took an average of 23 calls a month in the last fiscal year. They drove out to meet officers 144 times, as far as two hours away. Sometimes, they talked on the phone or via video to the officer or the person needing help.
There was the man with developmental delays whose dog had just been killed. He was a big guy, in "extreme distress," said Parker, who also is a trainer and expert in mental health crisis response. Police needed someone to help calm him down.
There was the woman who took her husband's gun out of a nightstand, fired it into the ceiling and took off. A deputy and a TASC counselor found her hiding behind a tree, delusional.
There was the troubled girl whose mother had called police twice in two days -- and, on the third day, the girl took off down a country road. It was time to get a professional involved.
There was the woman who called 911 because her husband was acting psychotic. Police got Parker on the line. After asking the wife questions, Parker suspected something else was going on -- not a psychological illness. He recommended taking the man to the emergency room. It turned out to be a brain tumor.
Chief Lacy said he wishes TASC had been around when he was a young officer and got called to a hospital for a mental-health crisis. The doctor couldn't tell Lacy where to send the man who was sick. The crisis center was full and couldn't take him.
"He was an indigent individual, didn't have insurance," Lacy said. "But I can tell you this: We dealt with him for probably up until six, seven years ago. So, I think it would be fair to say the failure at that time contributed to us dealing with him for the next 25 years."
Does TASC save money?
Law enforcement officials the Statesman interviewed during a recent trip to Nebraska sang TASC's praises.
The program has kept hundreds of people from ending up in the region's behavioral health crisis center -- the collection point where law enforcement in surrounding areas bring people in emergency protective custody.
TASC costs a little over $1 million a year for the 16-county region around Lincoln. Its funding source is essentially the money that would have paid for psychiatric hospital beds the state closed under a 2004 behavioral health reform law.
The law sought to shift money out of institutions, so people could live and get treatment in their own communities. Among other changes, the law mandated that Nebraska's six regions instead create crisis-response programs like TASC.
Some say the reform failed to reach its goal, or even made things worse.
"Hospitalizations because of mental illness surged by 20 percent across the state between 2007 and 2014, adding up to 85,000 stays during that time period, according to a report that assessed the state's behavioral health needs," the Lincoln Journal Star reported in June.
"(The people) went to the community, and the money didn't follow," a prominent advocate for mental health care told the Journal Star then.
Nebraska, like Idaho, has a shortage of psychiatric hospital beds. After reform, Nebraska has about 250 adult inpatient psych beds in state-run hospitals, and most of those are for people going through the justice system. The Journal Star reported last year that jail inmates with severe mental illness waited months for a bed to open.
Idaho has only 2 independent psychiatric hospitals. Now 1 is headed for bankruptcy.
But TASC Director Arnold Remington said the crisis-response program keeps people from needing a hospital bed, and that it pays for itself.
The cost of the full program is just over $1 million. That includes seven on-call professionals for the hotline and Remington's salary. It also covers 14 case managers who reach out to the client within hours of the call and help them for up to 90 days.
The savings from the hotline alone is at least $625,000 -- the cost of 250 crisis-center stays. Those savings grow significantly when accounting for the time law enforcement would've spent on the calls, and the amount hospital stays would've cost patients and taxpayers.
When the value of follow-up case management is included, Remington estimates the full program saves twice as much as it costs.
"Where the resources and the population are both scarce ... having someone who will come out, and then knowing there's another person who will follow up, it's a huge deal," Parker said.
Sometimes, the program simply pays for a trip home when someone is too isolated and needs family support, or a night in a motel when home isn't the safest place to be.
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About this project
This story is part of a yearlong Reporting Fellowship on Health Care Performance, sponsored by the Association of Health Care Journalists and supported by the Commonwealth Fund.
Since last winter, Audrey Dutton has been gathering stories about mental illness in Idaho, to examine the barriers to effective mental health care in rural Idaho, and look at possible solutions. She talked with dozens of people struggling with their own or their loved ones' mental illness, as well as first responders and mental health providers. She created a Facebook group where people can ask for help navigating the system, share their personal stories and stay updated on mental health news and events.
For this story, Dutton and visual journalist Darin Oswald traveled to Lincoln, Nebraska, to check out a rural mental-health crisis response program that gives law enforcement officers 24/7 access to counselors when responding to a mental health emergency. The program serves Lincoln and the 15 rural counties around it.
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Follow-up from case managers is key to the program's success, Remington said.
"The mobile crisis response is great for the immediate 'what do we do?' So the officers have got some resources," he said. "But it's really the ability to follow up -- if you can't get to your appointment, that's where you get your medications or your treatment. ... We don't want that officer being called back, so our plan should be thought-out enough and achievable enough."
He said the program has two jobs: "No. 1 is to give the officer options. No. 2 is to help the client. And we're working on both angles. Trying to get that officer back in service, trying to connect that person with resources."
Could TASC help in Idaho?
The Statesman learned about Nebraska's program from Steve Kunka, now Emmett's police chief. He was interviewed as part of a story on the death of Nigel Youngberg, a man who fled police while in psychosis and froze to death in April 2016. Youngberg had schizophrenia; his family repeatedly asked officers to take him to a hospital for treatment, but they had not.
Kunka started his career in Nebraska and left the year before the state's behavioral health reform law passed. But he knew about the program.
Kunka said Idaho's regional behavioral health staff has worked hard to help the department recently. He thinks they'll eventually be able to take people in crisis to Valor Health Hospital in Emmett, instead of having to drive them to a larger hospital more than half an hour away.
But what if Idaho had a crisis program that sent out mental health workers to help officers in the field?
"Absolutely I feel like that would be beneficial, to be able to do that before we place them on a hold," he said in an interview last month.
For one thing, it would make for a calmer response, he said.
"I wish I didn't say this, but it's true, that when law enforcement responds to a situation where a person needs assistance, mentally, they don't see that, right? They don't see us as help. They see us as 'law enforcement coming to punish us, take us to jail,'" Kunka said. "No matter how many times I tell them, 'We're here to help you.'"
And the program may have made a difference in some officer-involved shootings, specifically those involving people who were mentally ill and afraid of officers.
One example: Deputies in rural Elmore County fatally shot Matthew Conrad in August 2016 after a chase that started with a stolen truck and ended with Conrad waving a gun while standing on Interstate 84.
Conrad had a history of severe, chronic mental illness and had been hospitalized not long before his death, his fiancée, Jeannie Adamson, told the Statesman earlier this year. Whatever else contributed to his behavior that day, he hadn't been taking his medication, she said.
"He spent five days in the desert thinking stormtroopers, the Army Guard, were there with bayonet swords and ... he had to run from them," she said.
Adamson said Conrad was on his cell phone as he drove the day he died. She hung up and called 911 to talk with dispatchers.
"I said, 'Listen, he's scared to death. He thinks you guys are trying to kill him,'" she told the Statesman.
So far, 13 people have been killed in altercations this year with Idaho law enforcement. That's almost double the previous high of 7 people, as measured since 2000 through reports compiled by the Statesman.
The TASC program isn't meant to have counselors intervene in a situation like Conrad's. But it does give officers information they can use.
"One thing we might do differently in that type of situation ... is prior notification," Remington said. "So, when we have high risk individuals like that, we communicate with the sheriff's department ... and we do what's called a flagging system."
Anyone who TASC serves and who is under case management for longer-term help can agree to be part of the flagging system.
"When [officers are] on a call, and they run the name, a flag will pop up and say 'TASC,' and now the officer has a resource, and they can call the case manager" to get more information about the person and what may be going on, Remington said.
That flag also carries over to a nationwide criminal justice database. A park ranger in a neighboring state once called the TASC number listed on someone's flag, Remington said.
How would Idaho fund this?
Would Idaho lawmakers see TASC as worthwhile? Worthwhile enough to pay for?
"I think it's a tremendous idea," said Sen. Lee Heider, R-Twin Falls, who chairs the Senate Health and Welfare Committee.
Heider noted that Idaho has put millions of dollars behind opening new behavioral health crisis centers around the state. But most of them are in larger cities. And they're limited -- for example, people can stay only 23 hours and 59 minutes. Most importantly, Idaho crisis center workers aren't going out to the person in need; the person must come to them, which is tough in places like Salmon that are hours from the nearest center.
"Does that mean we would give up behavioral health centers to do that? Probably not," Heider said. "So the second question becomes: where does the money come from?"
He isn't sure the Legislature can consider funding a new program at the same time it is looking at ways to fund Medicaid expansion -- which passed on the November ballot as Proposition 2.
"Right now, money is the key component of almost any desire we would have as a state," he said.
Idaho paid $8M for 2,400 psych hospitalizations. Guess how much therapy that buys under Medicaid?
'Something is going to have to change'
Remington, the Nebraska TASC director, developed the program from scratch after talking with experts around the country.
He heard about the CIT model -- crisis intervention team -- that trains officers to recognize and deal with mental health emergencies. It's a model that Idaho agencies are trying. But Remington learned that it doesn't always work in rural areas, he said. For one thing, training takes 40 hours, which is a long time to have your deputy off the job. For another, not everybody is cut out for CIT work. And thirdly, small agencies may need to train every officer if they want to have true 24-hour CIT.
So Remington set up an 800 number, invited police chiefs and sheriffs to use it, and staffed it with counselors using the funding from the reform law.
The first year, calls trickled in -- 45 all year. The third year, 117. As word spread, more agencies started using the hotline.
"We try to use them as much as we can," said Gage County Sheriff Millard "Gus" Gustafson.
Unfortunately, Gustafson said, other law enforcement agencies in the area don't use the hotline. He guesses about 75 percent of the people brought to his jail have a mental illness.
"Jails have gotten to be the depository for mental health" problems, he said. "The system broke, and we don't have near enough facilities in the state to handle all of this. It's just -- it's killing the county."
Remington says that's a problem on the horizon. The crisis program can't solve it completely, but it can help, he said.
"You've got lack of mental health resources, and you've got corrections saying, 'We don't want to be a mental health provider,'" Remington said. "And I think at some point, that's just going to collide, and we're going to be in trouble. Something is going to have to change."
Her death leaves her family wondering: Did Idaho's health care system fail her?
Audrey Dutton is reporting on Idaho's rural mental health care as part of a yearlong Reporting Fellowship on Health Care Performance, sponsored by the Association of Health Care Journalists and supported by the Commonwealth Fund. Contact her at 208-377-6448, email@example.com or on Twitter at @audreydutton.
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