Dec. 23—The city’s mobile crisis team is still in a period of uncertainty, almost four months since it went on hiatus.
The first responder service — a partnership between the fire department, local nonprofit Substance Abuse Connect (SAC) and the Rimrock Foundation — operated for 11 months diverting mental health emergencies away from law enforcement by sending a Rimrock clinician and an EMT to mental health-related police calls.
The Rimrock Foundation pulled out of the program at the end of August, citing delayed reimbursements from the state, low call volume and difficulty finding clinicians to participate in a first responder environment.
The local program has now been awarded over $500,000 from the state, but its leaders have been unable to secure a new behavioral health provider or decide on how to improve the program’s model based on what they learned from the program’s initial run.
The service is widely supported by city officials. Diversion was once a position for socially liberal people upset by the human cost of incarceration, but it’s found an unlikely bedfellow in fiscal conservatives fed up with the high cost of sustaining an ever-growing number of inmates in county jails and the state prison.
Yellowstone County has a $6 million project underway to build a pre-arraignment holding facility. Another jail expansion project will likely require a levy vote.
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Gov. Greg Gianforte in November proposed to allocate $150 million in the upcoming legislative session to expand county jails and the state prison by a total of 500 beds. The state is spending $4 million annually to incarcerate 120 people at a private prison in Arizona, due to overcrowding at Montana State Prison.
The grant funding for the Billings program came from $7.5 million of Department of Public Health and Human Services (DPHHS) funding for mobile crisis initiatives to divert Montanans with behavioral health challenges out of jails, emergency rooms and Montana State Hospital.
Jason Banfield, assistant chief of the Billings Fire Department and the lead on the city’s program, estimates the grant funding from the state will be enough to sustain the team for 14 months.
A higher response rate would decrease the amount of local spending needed to support mobile crisis services once the grant funds are expended, by increasing the number of billable hours during a clinician’s 12-hour shift.
The unit responded to 474 calls over 11 months, or less than two calls per day, according to program data.
At a November city council meeting, Banfield suggested that the team swap its EMT for a paramedic, which could increase call volume by making the unit able to respond to more physical health emergencies.
The suggestion met resistance from supporters of mobile crisis services.
Councilmember Jennifer Owen pushed back against the proposal, arguing that the unit should instead focus on “more proactivity” and “more targeted finding of people in need.” She suggested that the program instead increase response volume and billable hours by being more of a patrol unit than a response unit.
Chyrel Garding, a business development manager at the Rimrock Foundation, voiced her concerns about the proposal during public comment.
“It’s virtually identical to model one, which is the pilot program we just ran and it didn’t work very well,” she said.
“Without an evolution from the first failed pilot project, shame on us for not doing our due diligence,” she continued.
Both Owen and Garding said that the problem was response rate, not call volume. Garding said that when she did a ride-along with the unit, the EMT had autonomy over which calls to respond to and chose not to respond to a public intoxication call, for example.
“It’s beneficial to respond to each of those types of calls,” Garding said.
Banfield and Zack Terakedis, executive director of SAC, did not respond to multiple requests for comment. Terakedis will be stepping down from SAC in the new year.
Lessons from Missoula
John Petroff, a firefighter and operations manager for Missoula’s mobile crisis team, said that higher response rates come with time. Missoula’s crisis team has operated for just over four years and call volume has more than doubled in that period.
“There are going to be low calls that build up until you can consistently show what you do,” he said. “You have to have the patience to say, ‘Yeah, we’re only running 474 calls, but next year it’s going to be 1,000.’ Just having the patience to follow through with it is a big part of it.”
Petroff said that now that his crisis teams are familiar with regular clients, they may ask law enforcement to respond to a call they see appear on their dispatch monitor because they know who the call is about.
Missoula now has enough call volume to support two teams that work 10 hours per day, seven days per week. Petroff’s program is bringing a third team online three days per week in the new year to respond to calls that come in during the 14 hours of the day the teams are off-line, as a face-to-face encounter is necessary for billing purposes.
The Missoula teams only respond to 215 calls per month, or about seven calls per day — which is only 3.5 calls per team. Petroff says the teams are busy all day long with care coordination, report writing and training — suggesting that it’s unrealistic to expect that clinicians could be on back-to-back-to-back calls on their shifts.
Petroff said that pushing for maximal efficiency means that clients “aren’t going to be taken care of in a way that will create change.”
“People want to see this happen for a reason,” he said. “We’ve just got to keep pushing for that over production and make sure that the calls they’re going on, they’re doing really well on. If we just get on and off the scene, it’s not any better for the system than fire or law enforcement.”
Given the ratio of care coordination to response time required for teams to meaningfully help the clients they serve, and the fact that coordination is reimbursed by Medicaid at one-fifth the rate of responding to calls, it’s unlikely that these teams will ever be sustainable without local investment.
The state’s Behavioral Health for Future Generations Commission (BHFGC) wrote that “utilization trends estimate that programs will not deliver the number of encounters needed to sustain the service through Medicaid reimbursement alone” when describing why it was recommending that DPHHS allocate funding for these services.
“I don’t want to say its not doable without (local funding), but with only federal and state funding you’re not going to be able to provide the services the state and county expect from it,” Petroff said.
Petroff believes that cities and counties need to be fiscally responsible, but that mobile crisis “reduces so many costs down the road,” through diverting people out of jails and emergency rooms. He said that local buy-in helps his case in requesting state and federal funding.
“It gives us the ability to go to the state and federal government and say, ‘We have buy-in and we need help,'” he said.
Crisis services in Missoula have received federal funding for crisis services through pandemic aid and grants from the Department of Justice.
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