The Montana Gap: Teamwork promises to help improve mental health care in Lincoln County

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Amy Fantozzi, left, manager of Lincoln County’s behavioral health network, and Jennifer McCully, the county’s public health manager, stand in McCully’s office in Libby Wednesday, July 11. The two have been key in helping the county respond to the closing of Western Montana Mental Health Center’s Libby office at the start of 2018. Their efforts have included leading a coalition of local mental health care and related service providers. (John Blodgett/The Western News)


The Western News

(Editor’s note: This story is part of The Montana Gap, a mental health reporting project produced in partnership with the Solutions Journalism Network.)

When someone suffering a mental health crisis arrived in the emergency room at Cabinet Peaks Medical Center in Libby, staff there often called Western Montana Mental Health Center, which would send a mental health professional to evaluate the case and determine a course of action.

But that practice ended at the start of 2018, following the Missoula-based center’s announcement that it would close its offices in Libby and Dillon. The reason: steep budget cuts made in Montana’s special legislative session last November.

The news sent public health staff and health care providers in Libby scrambling. Besides employing 13 people and serving about 200 clients, Western Montana Mental Health Center had been contracting with Lincoln County to respond to the ER crises, and the county had no backup plan.

A county-led mental health coalition hastily set out to determine how to replace the ER response, and what to do for the center’s clients who would soon be without therapy, prescription and other mental health care services.

The coalition met regularly for weeks. By the end of June, it had established a behavioral health network as the foundation of a still-evolving solution. Managed by the county, the network is comprised of mental health professionals who are paid a stipend for each ER visit, and who work as much on prevention as intervention. While it’s too soon to tell whether this will be the long-term fix Libby needs, its success or failure could have lessons for other Montana towns also struggling with mental health service cuts.

“We need to be empowering our community and implementing things that help build prevention and intervention measures, because we have to (consider), ‘How do we prevent crisis?’” said Amy Fantozzi, a public health staffer who helped form the network and now manages it. “Because we don’t have the resources here for crisis.”

Building a network

One of the immediate steps the county took was to contract for about six weeks with a former Western Montana Mental Health Center staffer to fill in for crisis response while also helping the coalition establish a more permanent solution.

From the county’s perspective, a mental health crisis is when someone has harmed or threatened to harm himself or someone else and has arrived at the emergency room.

By March 1, the county had established the behavioral health network, comprised of two health care organizations — Northwest Community Health Center and Sunburst Mental Health Center — and six or seven private-practice mental health professionals, three of whom will respond when needed to the emergency room.

Where Cabinet Peaks Medical Center staff once called Western Montana Mental Health Center, they now call Fantozzi. What happens next depends on whether the person is drunk or high, which Fantozzi said is often the case.

“A lot of times they end up staying overnight ... until they’re free of whatever drug or alcohol is in their system at the time of arrival,” she said.

Once the person’s system clears — and if the person is judged to be suffering a mental health crisis — Fantozzi calls the three standby mental health professionals until she finds one available.

“Once we send somebody in, they’ll do an evaluation,” Fantozzi said.

Much of the time, the evaluation results in a referral to local outpatient services, Fantozzi said. The mental health professional and the patient create a “contract for safety,” an agreement that often includes making an appointment with a mental health care provider.

“That’s where the network really comes in handy,” Fantozzi said, noting that most of the time she or the mental health professional can call a network provider and find an opening, ideally that day or the next.

Sometimes, the mental health professional, after the evaluation, determines that inpatient care is necessary, requiring the patient to seek treatment outside of Libby. Pathways Treatment Center in Kalispell is the closest facility and most often recommended; two other nearby facilities are Glacier House, also in Kalispell, and Lake House in Polson — both of which are run by Western Montana Mental Health Center.

If the person agrees with the need for inpatient care — a situation called voluntary commitment — the mental health professional will help with placement and filling out the necessary paperwork.

If the person is unwilling to seek the required inpatient care, it becomes a case of involuntary commitment. The person is placed in a 72-hour hold at the medical center, the county attorney is notified and a court hearing is scheduled. Such cases require more of the mental health professional’s time, including additional paperwork and appearing in court, before the person is sent for treatment.

Preventing mental health crises

Public health officials have sought not only to plan for emergency-room response, but to point people with mental health issues to other resources before they reach that crisis stage. The goal, called diversion, seeks both to reduce the load on limited resources and to improve people’s wellbeing.

Part of diversion, Fantozzi said, is informing the public about what mental health or related resources exist locally. In addition to the behavioral health network, and in recognition of the high correlation between substance abuse and mental health issues, she will refer people, when appropriate, to Flathead Valley Chemical Dependency, Celebrate Recovery and local chapters of Alcoholics Anonymous and Narcotics Anonymous.

Another part of diversion is training people how to spot potential mental health issues in others. To that end, Fantozzi established a county-funded Mental Health First Aid program, outside the behavioral health network, after she was trained and certified earlier this year to teach it.

The first training, held April 30, went “fabulous,” Fantozzi said. Seventeen county employees — including sheriff’s deputies, public health staff and a county commissioner — attended the eight-hour course, took the quiz at the end and were certified for three years.

Mental Health First Aid training enables people to recognize when someone might be showing early signs of a mental health crisis or suicidal behavior, Fantozzi said. Those who receive the training now know what to say, what to ask, how to listen and how to help that person get help, she said.

“You want to help people in the early stages of illness find help before it gets to a point where it’s affected their ability to live, laugh and love,” Fantozzi said.

The Mental Health First Aid website at lists numerous studies of the program’s efficacy. One study from earlier this year, funded by the National Health and Medical Research Council in Australia, where the program was created, found it to be “a noteworthy contribution to improving the lives of people with mental health problems.”

Assessing early results

Overall, Fantozzi said there have been fewer roadblocks and obstacles than expected in responding to Western Montana Mental Health Center’s closure.

“Things are going well for the most part,” she said.

From the start of March to the end of June, behavioral health network providers performed 31 evaluations at the medical center, plus two at the jail and one at the senior care center. From those, six voluntary commitments and eight involuntary commitments resulted.

Jennifer McCully, Lincoln County Public Health manager, said it’s too soon to draw comparisons with previous years’ results.

“However, something to note is that we usually have 12 to 15 involuntary commitments each year, and already since March we have had eight,” she said, indicating that the workload for the fledgling network has not been light.

What’s not reflected in those numbers is the increasing number of evaluations done by medical center staff. Though only specially certified mental health professionals can work on involuntary commitments — and the medical center has none on staff, nor does it employ mental health professionals per se — Fantozzi said doctors and physician’s assistants are sufficiently educated to evaluate many mental health crises, and some do.

What some might lack, she said, is the comfort level that comes from regular experience with evaluations, which more often than not in the past were left to Western Montana Mental Health Center.

Weighing in from outside

A consultant with the National Council for Behavioral Health of Washington, D.C., Joan King has been to Montana more than 30 times since January 2016 to help communities with integration, or the merging of physical and behavioral health systems.

Having consulted statewide, King said she finds Lincoln County’s response particularly compelling.

“Your community has come together to say, ‘Nobody is going to save us, and we need to figure out how we can use the resources we have while advocating for other resources to meet the needs of ... our community,’” she said.

King has been meeting with the county’s mental health coalition since before the Western Montana Mental Health Center closed, consulting with the group as part of a previously awarded Montana Healthcare Foundation grant.

She recalled a meeting in January, soon after the center’s closure, where she was struck by the attendees’ love for and commitment to the community and a “need to make this work.”

“That is very powerful,” King said. “That doesn’t mean that there aren’t going to be bumps, and that there isn’t still a need for probably a higher level of care than the community is able to provide at this point. But right now they’re going to figure that out, and then it’s going to be a question of, “How do we get the resources we need?’”

Planning next steps

One crucial need public health officials want to fill is case management, which McCully said is the county’s “next big step,” and one that will help encourage continuity of care for patients.

“How do we make sure that they got to their appointment?” McCully asked. “How do we make sure that they’ve actually gotten the services that they need, and what level of follow up can we and should we do?”

With the Western Montana Mental Health Center gone, only Sunburst Mental Health Center offers case management locally, and its caseload is “overflowing,” Fantozzi said. The county therefore wants to find ways to help those returning from inpatient care to stay on track with their follow-up care, she said.

Billing also remains an issue for paying the network’s mental health professionals who respond to emergency room crises. For now, the county offers a $100 incentive, an amount Cabinet Peaks Medical Center recently agreed to match. The county pays an additional $300 for the extra time a mental health professional works on an involuntary commitment.

The county incentives — for now, at least — are paid out of the $18,500 the county previously budgeted for Western Montana Mental Health Center’s services.

“We have committed funding for this interim incentive plan for next year,” McCully said. “However, we are still looking for long-term, sustainable solutions.”

Other pieces of providing broader mental health care in Lincoln County are starting to fall into place. The county recently received a Montana Healthcare Foundation grant to combat substance use disorder, and seeks funding to expand the Mental Health First Aid program.

In addition, the public health department arranged for Karl Rosston, suicide prevention coordinator for the Montana Department of Public Health and Human Services, to come to Libby July 19 to introduce health care providers and others to the suicide assessment five-step evaluation and triage (SAFE-T) protocol.

In augmenting the awareness raised through the Mental Health First Aid program, Fantozzi and McCully anticipate that the SAFE-T training will contribute to diversion.

They also hope the training will help overcome the stigma of mental health and substance use problems, “because a lot of people aren’t reaching out for help because they feel like they’re going to be stigmatized,” Fantozzi said.

Taking stock

It’s too soon to tell whether the behavioral health network will be a long-term fix for filling Lincoln County’s mental health care needs, or what a broader solution might encompass. But the leadership is in place to start planning for the longer term.

Fantozzi said the network’s development “has been the biggest, most positive” result of Western Montana Mental Health Center’s closure.

“The fact that public health has stepped up and integrated mental health and behavioral health into the public health system is really huge for our county and for the state,” she said. “I don’t know of any other (Montana) county that has mental health in their public health system.”

Fantozzi praised the coordinated effort undertaken by the mental health coalition, saying that “everyone’s worked really well together.”

King noted that pulling together various community resources to build a network can’t happen without leaders such as Fantozzi and McCully, citing their tirelessness, commitment and passion.

Even when calls or meetings have begun with discouraging news, King said their attitude by the end has been “we live to fight another day.”

“That’s why things are happening [in Lincoln County]” King said. “Because they’re the catalyst to bring people together.”

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