Jail and emergency rooms.
Those are the two places many in mental health crises wind up. And law enforcement as well as the mental health community say those are two of the worst places for people who need help, not punishment.
A new report by Inseparable, a mental health advocacy group that is dedicated to influencing policy and the people who make it through data-driven decisions, shows the state-by-state response to mental health crisis support varies. It also shows that with a few policy changes, states could become more effective, and possibly spend less to help those in crisis.
In Montana, the state’s snapshot showed progress, but leaders of the organization say the Treasure State hasn’t built out as many programs and services as other states to address mental health crises.
Angela Kimball, the lead author of the report and Inseparable’s Chief Advocacy Officer, said that while Montana’s network for supporting those in a mental health crisis is not exactly robust, it finds itself in similar company as many states look for new models, without relying so heavily on incarceration or hospitalization.
Furthermore, Kimball praised the work of Montana Gov. Greg Gianforte for dedicating funds to address mental health crises, as well as that of Rep. Bob Keenan’s efforts to help distribute $300 million to agencies statewide to help address mental health and other challenges. The Bigfork Republican’s initiatives included House Bill 872, which went into law last year, establishing the Behavioral Health System for Future Generations commission made up of legislators from both parties.
Montana’s snapshot
While Montana has made more progress than some states, Kimball sees Montana as a state still learning and developing its approach.
For example, the Treasure State scores well in metrics for its 988-call center. 988 is a national suicide and crisis help line that each state supports. The national goal is to answer the line in more than 90% of cases. In Montana, the call-answer rate is 96%.
However, to meet its needs statewide, the report says that Montana would need to have 17 mobile crisis response teams, 58 “crisis receiving chairs” and 50 short-term crisis beds. One of the challenges is that there is no overarching state or federal agency that collects and monitors data on response teams or facilities, making it difficult to pinpoint how close Montana is to some of the goals of the report.
For example, Billings, Helena, Missoula and Bozeman all have established a similar response team or program, but that data is reflected only at the city or county level, not reported to state or national agencies.
So far the report said that Montana has virtually no accountability for the types of services it offers or where the services are located. Some states have created a crisis system board which oversees, coordinate and reports on the mental health needs. Montana also does not have regular legislative reporting and data collection. Experts say creating a systemic approach is important because it keeps community partnerships strong, and encourages transparency for the public funding portion and data collection, which is nearly non-existent.
Montana allows an enhanced Medicaid match for mobile responses, one of three key areas for system financing, according to the Inseparable report. However, it lacks a 988-phone surcharge, and commercial insurance coverage does not typically pay for these short-term and mobile responses to mental health crisis. Both of those items could be used to improve and enhance services statewide, the report said.
Comparatively, Montana also is faring better than most of its neighbors. None of its neighbors have the enhanced Medicaid funding, and no other neighboring state has a 988-call center answer rate higher than 90%.
However, Wyoming does have a crisis system advisory board, coordination, legislative reporting and partial data collection.
Other examples
One of the reasons Inseparable prepared the state-by-state report was because of the different approaches that states are implementing. However, Kimball said there’s no one federal agency responsible for monitoring or tracking individual state’s response to mental health crisis.
“There is just no national data on this,” Kimball said. “Anecdotally, we do not have crisis stabilization capacity despite admirable efforts from law enforcement and health care providers.”
Kimball said that often the most costly resources are deployed to people in mental health crisis — emergency room doctors and staff, and law enforcement officers. But, neither are good solutions. Kimball said that law enforcement often need to be doing other tasks related to public safety, and emergency rooms can be used for other health emergencies.
Instead, Inseparable advocates for an approach of outreach and stabilization. One of the notable improvements has been 988 call centers, which are meant to help reach and assess those who are in mental health crises or struggling with suicidal ideation.
Kimball also said that mobile response teams, often located throughout a state, can respond to calls that most often would involve law enforcement and ambulances. The idea is to send responders trained in mental health crisis to intervene, rather than paramedics and police. This also helps to keep people out of jails or hospitals. Instead, people struggling with a mental health crisis go to 23-hour crisis “chairs” and short-term crisis beds.
“It’s more of a living-room type environment,” Kimball said.
The idea is that safe environments can be created for those who need stabilization. Sometimes that’s a chair or a bed with other support services to help calm a crisis, rather than a more intensive in-patient hospital stay. Plus, many patients like the approach better because it is not as severe.
In a state such as Montana, with a huge amount of geography and a smaller population, this model can be a challenge, Kimball said. However, that’s why the report included many examples of what other states are doing — some rural, like Oklahoma and Utah, and many politically conservative.
For example, Arizona and Oklahoma have partnered together to create a dispatching service that can send mobile crisis response teams on the road for both states, eliminating the need to have multiple dispatching call centers.
Oklahoma also sends first responders with tablets that have broadband connectivity so that when the responders arrive on scene, those in crisis can speak directly and immediately with a person trained in mental health crisis.
“You have to leverage the personnel where they live,” Kimball said. “And then you leverage the technology that exists.”
But it was a different health crisis that helped groups like Inseparable advance ideas quickly.
The COVID-19 shutdowns and emergencies forced healthcare providers, law enforcement and insurance companies to think differently about delivering health care. Also, patients got more comfortable with remote appointments. That led to new crisis stabilization models without waiting for the slow and somewhat patchy network of states and regions to buy into the idea.
“Mobile response teams, including specialized youth response, should be available to reach anyone who needs in-person support anywhere, anytime. Instead of relying on law enforcement to respond to crises, states should shift to specialized mobile response teams that have professional and paraprofessional staff, including peer support specialists,” the report said.
The report recommends a call dispatch center that looks a lot like the ones EMS and fire department uses.
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