How behavioral health leaders are scaling crisis response for every corner of Alaska

Presented by Alaska Mental Health Trust Authority

Part 6 of 6

The Crisis Now framework for behavioral health intervention was first implemented in Phoenix, Arizona, a city of about 4 million people in a state with a population of more than 7 million. Developed by a task force of the National Alliance for Suicide Prevention, its matrix of services -- a call center, mobile response teams, crisis stabilization centers and peer support -- serves more than 20,000 individuals in crisis every year, is estimated to have saved millions of dollars in health care costs, and is being adopted or considered by more than a dozen other states.

Now that a coalition of Alaska organizations, led by the Alaska Mental Health Trust Authority and the Department of Health and Social Services is trying to bring the model to Anchorage, Fairbanks and the Matanuska-Susitna area, there’s one big question this coalition is trying to answer:

Will what works in Arizona work in Alaska?

Proponents say that while the individual components may need to function somewhat differently, the framework can absolutely be translated to Alaska’s largest communities, where the effort is being concentrated.

Off the road system, the new model is more challenging to implement, but behavioral health care providers in several regions say Crisis Now can be modified to fit their unique needs -- or, at the very least, relieve pressure on statewide resources that will have benefits for any Alaskan in crisis, no matter where they live.

In Nome, fewer people, but equal need

Far off the road system in Western Alaska, the head of behavioral health for one regional provider says population and resources might make implementing the full continuum of Crisis Now services unrealistic for his area, but he’s hopeful that its arrival in the bigger cities will have trickle-down benefits.

Recognizing the need to improve response to those in crisis, Lance Johnson, behavioral health services director for Nome-based Norton Sound Health Corp said, “We realized years ago … we had to have a team that just dedicated their time to that.”

NHSC has invested substantially in behavioral health in an effort to provide as much in-region, culturally relevant care as possible. The hospital in Nome has psychiatry available seven days a week on-site as well as through telehealth. NSHC also provides full-time on-call behavioral health urgent care staffed by three master’s level clinicians, so there’s always someone available to answer a call in Nome or any of its 15 surrounding villages. Through the expansion of these services, NSHC has been able to address more behavioral health needs at home, sending fewer patients away for care in larger cities.

“We’ve seen such a great change with psychiatry and with behavioral health services,” Johnson said. “We’re mitigating the need to send (patients) to API or Mat-Su.”

Even with its expanded capabilities, NSHC is the sole local provider of behavioral health services to the 10,000 people living in the region, and it isn’t able to address every need.

“What we’re missing is the higher level of care that we do need to be able to keep somebody here,” Johnson said. “We can only do so much here.”

It’s a microcosm of Alaska’s statewide dilemma: There aren’t enough behavioral health care beds, especially for mental health, and especially for pediatric patients. The successful Bring the Kids Home effort of the early 2000s has started to lose ground, Johnson said, and more young Alaskans are being sent Outside for care.

“They end up in Utah,” he said. “They end up in Arkansas. And that just can’t happen.”

Nome’s reality, he added, is that the region simply isn’t populated enough to support all of the services it might possibly need. But he is hopeful that adoption of the Crisis Now model in larger communities will help alleviate pressure across the system by intervening earlier and helping to reduce demand for the high acuity beds at API. The crisis call center could potentially have an immediate impact in rural areas, Johnson said, where the small population can sometimes act as a deterrent to seeking help.

“Sometimes somebody will not reach out to behavioral health services because of a historical concern that they had -- maybe they didn’t get the help that they needed -- or the stigma of localized care,” he said. “I’m really curious to see how they’ll field out those calls, how much counseling they’ll be able to do on the line.”

There are some parts of Crisis Now that may not work in remote areas -- urgent in-person response to a village, for example, is limited by travel time and conditions. But Johnson said he’s intrigued by the possibilities and looks forward to working with other regional health care organizations to figure out what can work on a reduced scale.

“It’s going to be a different beast, but I think there are things that we’ll learn with the Crisis Now model,” he said.

Planning for a Kotzebue-sized Crisis Now

Just under 200 miles to the north in Kotzebue, behavioral health providers see not only a benefit to Crisis Now -- they see the possibility of scaling it to their community.

The crises that represent the greatest need in Kotzebue are those stemming from substance use, particularly alcohol, according to Bree Swanson, social services administrator for Maniilaq Association, the Tribal nonprofit serving the Northwest Arctic region.

“That’s the population of people that probably are falling through the cracks, to a certain extent,” Swanson said. “We don’t have a detox center. We don’t have a Crisis Now bed that can hold them for 24 hours and get them stabilized.” Often, people in an alcohol-related crisis are simply released back into the community.

Swanson herself has experienced the frustration of trying to help a loved one get into treatment. Over the winter, she helped a family member who was hospitalized for a medical issue apply for substance use programs. By the time the relative could get into treatment, she had stabilized too much to get into the high acuity beds that were available, but she wasn’t well enough to get into a lower acuity bed. It would be more than two months before a bed at her level opened up -- and in the interim, she relapsed four times.

“That’s not a unique story,” Swanson said. “When you’re dealing with substance abuse, sometimes that window of opportunity is so small -- and if we fail to reach somebody during that window of opportunity, we may have lost them for the rest of their life.”

Over the past year, some improvements have been made. Maniilaq used COVID-19 response funds from the Substance Abuse and Mental Health Services Administration to hire a case manager, and medically assisted treatment is now available through the Kotzebue hospital. But there is no inpatient care for substance use, and patients who come in during off hours have to wait until outpatient programs open the next day.

Maniilaq serves a population equal to about 0.2 percent that of Phoenix. But Swanson said the framework has the potential to make a huge impact when adapted to fit the Kotzebue region. Maniilaq is already working on a capital funding request to remodel their hospital to create Crisis Now beds. Currently the facility has one room that is safe for someone who poses a risk to their own or others’ safety.

“That happens on a regular basis here,” Swanson said. “We have to open whatever beds are available. It just creates a risky situation for everybody involved.”

With the Section 1115 Medicaid waiver in place, she added, Maniilaq staff are hopeful that they can adopt a version of the Arizona model that works for Kotzebue.

“Crisis Now has so much hope for us,” Swanson said.

Full speed ahead in Juneau

To see Crisis Now in action in Alaska, just look southeast. Juneau’s Bartlett Regional Hospital is well on its way to adopting the model, according to Chief Behavioral Health Officer Bradley Grigg.

“We’re committed to Crisis Now,” Grigg said.

Until recently, behavioral health services were provided at Bartlett Regional by partner organizations on an on-call basis. That changed in 2019 as the hospital began to integrate behavioral health into its emergency department. Although Bartlett Regional doesn’t have a separate psychiatric emergency department like Providence Alaska Medical Center in Anchorage, it is now able to offer on-demand services provided by master’s-level clinicians. At the same time, the hospital is preparing to break ground on a new building, funded in part by the Trust, Rasmuson Foundation and other partners, that will house a flexible, eight-bed behavioral health facility that will serve both adults and youth, with a projected opening in summer 2022. The facility will allow the hospital to offer the 23-hour stabilization that is a key component of the Crisis Now framework, among other services.

“The problem is, the crises are not waiting on the building,” Grigg said.

To bridge the gap, the hospital has launched a home-based crisis intervention service that connects with families after a crisis. Launched for pediatric patients in January, the program will soon be expanded to include adults.

“If they’re in crisis, we want to serve them,” Grigg said.

When complete, the new behavioral health center may serve as more incentive to seek care, especially for young patients. Often pediatric mental health patients in the Southeast region have to go to Anchorage or Seattle for care. The new center will provide more access to care close to home, making it less of a hardship for families affected by a crisis.

“The whole Crisis Now model is within the thread of our DNA now,” Grigg said. “It’s who we are.”

Across Alaska, ‘people are trying to get help’

From the Northwest Arctic to Southeast, big city to small village, there’s one consistent thing on which stakeholders seem to agree: Alaska’s behavioral health care system is falling short, and something has to be done to fix it.

The prevalence of behavioral health crises has been increasing across the state, according to Elizabeth Ripley, president and CEO of the Mat-Su Health Foundation.

“Everybody’s impacted,” Ripley said. “There are better ways to do this. The worst part is, people are trying to get help” -- and when they do, the right services often aren’t available.

Alaska’s behavioral health leaders say more options for care are needed at all levels, especially for the many people who experience co-occurring mental health and substance use disorders. Crisis Now is intended to alleviate demand across the continuum of care and free up resources that are being stretched thin or misapplied. If it works in Alaska like it has in Arizona, it should reduce strain on law enforcement and first responders, emergency rooms and correctional facilities, provide opportunities for intervention before patients require more acute care, and help get people into recovery without inappropriately involving them in the criminal justice system.

“I am firmly convinced that Anchorage, and other Alaska communities as well, want to do right by people whose challenges are often very obvious -- they just don’t know how,” Trust CEO Mike Abbott said. “This can be a way that, as a community, we can improve the overall community condition in a way that also helps people that are clearly struggling.”

Solving those problems should have a positive impact on the community as a whole. For families like Ellen’s, the benefits could be life-changing, not just for people in crisis, but for the parents and loved ones who have tried everything they can think of to help.

“When you can’t control this, you feel that you’ve let yourself down,” said Ellen, whose name has been changed to protect her family’s privacy. “We think it reflects upon us as parents that we’re terrible parents.”

While she is grateful for the police officers, mental health practitioners and social services providers who have helped her family over the years, she added, it’s clear to her that a different approach with different and the appropriate level of resources are needed to make a lasting difference for her son and other Alaskans who experience behavioral health disorders.

“There have got to be better options,” Ellen said.

Read the rest of the series: Part 1 - Part 2 - Part 3 - Part 4 - Part 5

The Alaska Mental Health Trust Authority is a state corporation that administers the Alaska Mental Health Trust to improve the lives of beneficiaries who experience mental illness, developmental disabilities, chronic alcohol or drug addiction, Alzheimer’s disease and related dementia, or traumatic brain injuries. Learn more at AlaskaMentalHealthTrust.org.

This story was produced by the sponsored content department of the Anchorage Daily News in collaboration with the Alaska Mental Health Trust Authority. The ADN newsroom was not involved in its production.