Here’s what often happens when someone in Jefferson County suffers a mental health crisis:
That person calls 911, and a Sheriff’s deputy responds. Most deputies are trained in crisis intervention, so they can evaluate people on the scene for mental health issues — “We’re trained to ask tough questions,” says County Sheriff Tom Grimsrud. But they must do so often at the same time as they’re evaluating a potential crime.
Officers decide whether people are a threat to themselves or others. Those that are may be put in a squad car or an ambulance, depending on the circumstances — some transported to jail, others to an emergency room.
“It’s a decades-old challenge,” Grimsrud says.
Over the last 20 years, mental health and law enforcement professionals nationally have come to agree that the way such crises typically are handled is less than optimal — either for the people in crisis or for the first responders and health care institutions that provide immediate care.
A new approach has emerged called “Crisis Now,” geared to provide people in a mental health crisis effective and appropriate care that more often avoids unnecessary and often costly use of law enforcement and emergency medical services. That model, which combines a dedicated 988 suicide and crisis call line with mobile crisis responders and community-based centers for short-term therapeutic care, has spread across the U.S., including, since 2020, in Montana.
Jefferson County’s health department has begun studying the Crisis Now model. “Access to mental health care and services is a huge need,” says Public Health Supervisor Pam Hanna, who has had conversations with officials in Lewis & Clark, Gallatin, and Butte-Silver Bow counties about possible partnerships.
The challenge: Like much of health care, Crisis Now has thrived most often in population-dense areas with access to plenty of mental health providers — and in Montana, it has been most fully developed so far in bigger counties such as Yellowstone, Missoula, and Gallatin that have urban centers.
Can it work in rural places where care tends to be far less accessible?
“It’s fair to say that this is very much a model that fits closer to an urban setting,” says Scott Molloy, who directs behavioral health programs at the Montana Health Care Foundation, which is working to catalyze and coordinate Crisis Now efforts in the state. “But it’s hard to debate that those elements don’t apply to rural areas, too.
“How it looks in an area with lower population and resources is where the beauty of communities come out. It is still very young, in terms of how elements are being implemented. But the core is about bringing together partners in the community and having discussion to ask how do we make this happen in our community.”
In Lincoln County, a promising start
The Crisis Now model launched in Lincoln County in 2021 – mostly because Vanessa Williamson, the county’s Probation Department new pre-trial supervision officer, decided: “We need this in our town.”
Lincoln County is much like Jefferson in some ways. Its population of about 20,000 is spread out over 3,675 square miles, anchored by the small and remote communities of Libby and Eureka. For some, mental health needs are acute: Between 2013 and 2022, the county’s suicide rate was 31.2 per 100,000 population, according to the state Department of Health and Human Services (DPHHS), above the state average of 26.4.
“The initial response I got was that rural communities had hard time sustaining program like [Crisis Now],” Williamson said. “In rural areas, we don’t have resources that urban areas have, so we realized we need to work together.” Williamson assembled colleagues from across the county – the Sheriff’s office, municipal police departments, and therapists, and she won the support of her boss, Justice of the Peace Jay Sheffield. Without knowing exactly what their program was going to look like, they agreed to apply for grant funding.
An initial DPHHS grant paid for a vehicle. It also had funding for therapists, but Williamson knew there wasn’t money enough to hire full-time staff, and she didn’t want to take any of the county’s few licensed therapists out of the community.
And so came the critical innovation: an on-call model that contracted with therapists from the community to be available nights and weekends. That provided 24/7 therapist availability — although Williamson admits that the six therapists are mostly in the Libby/Troy area; calls in Eureka are harder to staff.
The county created a dedicated call line, available only to dispatchers and first responders, so they could easily reach therapists when crises emerged. (People in crisis still call 988 or 911.) And the following year, Williamson and her team realized another piece would be important — a care coordinator who could connect with first responders, therapists, and patients, ensuring follow-up services to those who need them. A new grant has covered that position, which started last year.
Williamson says the total budget for six on-call therapists and the care coordinator is about $100,000 a year, all funded by grants up to now. Is the expense worth it? In the fourth quarter of 2023, Libby’s Crisis Now system served 136 individuals; of those, Williamson says, 19 were diverted from a hospital emergency department, and three from an in-patient admission. In past years, she says, Sheriff’s deputies have had to take as many as 15 people in crisis a year to the Montana State Hospital in Warm Springs — a five-hour trip. Last year, they transported just two.
Building connections and partnerships
The implementation of Crisis Now in Glacier County and the Blackfeet Nation is at a much earlier stage — and making it happen likely will be more challenging than in Lincoln. “It’s certainly harder than I would have expected,” says Kirsten Krane, co-founder of Yarrow, a public health consulting firm focused on rural and tribal communities.
A year and a half ago, Yarrow and the Piikani Lodge Health Institute, a native-led health non-profit serving the Blackfeet people, won a two-year Montana Healthcare Foundation grant to pursue the foundational spadework for Crisis Now. What they found: Rural mental health is more complicated than it seems — as is bringing together law enforcement, health, and cultural actors across county, city and tribal lines.
The partners have focused on what’s called “sequential intercept mapping” — basically, figuring out how, when and where people in crisis engage with the existing system, and how all those actors and resources connect to each other, or don’t.
“It’s been absolutely eye opening to everyone involved, how many different programs and entities are involved when someone has a mental health crisis, and the complexity of coordinating everything,” Krane says.
For the system to work well, first responders have to be trained in crisis intervention. Then they have to be able to coordinate with other providers, private and governmental, at the county, tribal and state level. “A lot of what we’ve been doing,” Krane says, “is building relationships between these organizations and educating them. All of this is so new, and each sector only knows their sector.”
There’s the essential problem of finding and supporting rural caregivers. “We have enough problems supplying mental health professionals 9 to 5,” Krane says. “Add on 24/7 and hundreds of square miles, and it’s really difficult.” The challenge isn’t just about reimbursing those who provide care. It involves figuring out child care needs, and training therapists to work effectively via telehealth for remote patients — “all these micro things.”
The good news: The 988 service is gaining traction. As tribal agencies have increasingly marketed the resource, calls to the crisis line tripled in the second half of last year, albeit from a low base. The question is, what happens next? Who will 988 staffers, who aren’t necessarily local, contact to coordinate on-site care? How can the county and the nation make do with scarce provider resources?
Over time, Krane says, a 988 system with consistent response and follow-up, and first responders who are trained to intervene in crises, will become the backbone of strong mental health crisis programs for rural communities like hers. But “that’s going to take a long time to build.”
Statewide, local solutions are key
In 2020, DPHHS partnerered with the Montana Healthcare Foundation and the Montana Public Health Institute, among others, to develop a statewide strategic plan to improve and expand access to behavioral health crisis services, anchored in the Crisis Now model that had been described by the Substance Abuse and Mental Health Services Administration’s National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit.
Two related funding programs were already in place. County and Tribal matching grants, like the one awarded Lincoln County, offered funds to support community-based treatment, and encouraged collaboration between law enforcement and health entities.
And in 2019, the state Legislature had passed HB660, which seeded three mobile crisis units. Subsequent funding has helped expand the deployment of mobile crisis units to seven counties, according to DPHHS. And the Gianforte administration on Jan. 22 announced that it would allocate $7.5 million to mobile crisis response and crisis receiving and stabilization services — part of $300 million earmarked by the governor last year for behavioral health and developmental disabilities services systems.
The efficacy of those operations has been “highly dependent on the strength of local service coordination, often in the form of local behavioral health crisis coalitions,” said DPHHS Communications Director Jon Ebelt in an email.
More broadly, he said, behavioral health demands locally tailored responses: “Due to our state’s unique demographic makeup, its expansive topography, and our rural and frontier nature, Montana’s implementation of any national guidance will require customization. There are aspects of the Crisis Now model that are not feasible or practical in all communities across Montana and do not account for our state’s unique needs. This is why DPHHS uses the Crisis Now Model as a roadmap, knowing that some alterations will be made to fit the needs of our state.”
In Jefferson County, a long road
In October, Hanna, Kristel Kishbaugh, a psychiatric nurse practitioner in Montana City, and Erin Ritchie, the county’s public school health nurse, attended a Crisis Diversion Summit to learn more about Crisis Now. Following that, Hanna hosted a meeting with peers from Lewis & Clark and Broadwater counties as well as Molloy from the Montana Healthcare Foundation. Other meetings have followed, including a range of actors including Grimsrud and Barb Reiter, the county’s prevention specialist.
The need for a better crisis response model seems clear, with a wide gap in Jefferson County between demand for mental health services and their availability. In a 2019 community health survey, 53% of respondents cited access to mental health care as a top concern. The county’s suicide rate between 2013 and 2022 was 38.1 per 100,000 population, according to DPHHS. “We need to be able to get to people” in need, says County Commissioner Bob Mullen, who has worked to improve mental health access in the area.
Mullen, Hanna and others believe that Jefferson County can’t support Crisis Now on its own. For one thing, there probably aren’t enough therapists, and most are concentrated in the north and south ends of the county; an effort in 2021 to bring a part-time therapist to Boulder failed, for a variety of reasons. A mobile crisis response unit operated by St. Peter’s Health in Helena serves parts of Jefferson County, but its availability isn’t guaranteed. And there isn’t the population to support a center for short-term therapeutic care like those in cities.
Instead, Hanna hopes to partner with one or several larger neighboring counties who may be better positioned to receive grant funding that would allow Jefferson to start a mapping process like that in Glacier County and Blackfeet Nation. How many people need crisis services? What are they doing now to engage with the system? What are the points of connection and intersection? “We need the framework, and we need data,” Hanna says. “You can’t build a strategy if you don’t know what’s happening.”
Meantime, the 988 call line is only starting to gain visibility and use. Last year, according to the Montana Healthcare Foundation, there were 20 calls to the line from Jefferson County; at least 80% of those calls were resolved over the phone, indicating that they didn’t escalate to requiring in-person intervention. (DPHHS says that, statewide, 988 call centers received 10,476 calls in 2023.) Grimsrud says he’s considering adding a decal advertising 988 to his deputies’ vehicles.
The progress in Lincoln County demonstrates that providing effective mental health crisis support in rural areas is possible. The experience of Glacier County and the Blackfeet Nation reveals the work and collaboration that’s needed to get there. And the state’s experiments and investments show that there’s not a single best path.
But “it’s a model that’s been tested all over the country, not something brand new,” Mullen says. “I think it can work.”
