Mental health crisis care frustrates officials

Filiberto Ontiveros, chief of operations for the county Department of Emergency Management, said that the relationship between DCRs and county dispatchers has been good until recently. When requesting services of a designated crisis responder, in the past the DCR would normally make contact within minutes. But this April marked a turning point.

Ontiveros said the first incident occurred April 17, when a county official dialed the crisis line number but never received a call back. The second incident occurred days later on April 20. Ontiveros was on scene as a volunteer when a call was made to the crisis line, which responded that no Designated Crisis Responder was available to respond at that time.

“There’s been several times where we call the crisis line, and they’ll refuse the call, they’ll refuse to call out a DCR and state when the hospital calls, they’ll take care of it,” Ontiveros said.

Because of the no show, officers were forced contact family and provide alternate resources; as well, Ontiveros raised concern that the situation limited the officer’s ability to respond to the next call.

“A lot of times now … a 911 call comes in from a person in crisis, and it’s oftentimes now going to the crisis line,” he said, because the county does not have resources available at the moment. Given the time-frame, he said it could amount to a level where the individual hurts themselves. “It’s always a gamble.”

The county 911 official had raised the concerns during a May 26 meeting of the Board of County Commissioners. Present during the meeting were two representatives from Comprehensive Healthcare, the sole nonprofit organization with a contract with Klickitat County to render crisis services.

Ron Gengler, chief clinical officer with Comprehensive Healthcare, was joined by Edie Dibble, chief operating officer, to respond to concerns from county officials about their current staffing situation.

Dibble noted that Comprehensive Healthcare and the crisis line are managed as separate entities, “and we do work with them, so to speak. And so, as we hear hiccups, we’ll dig in and try to figure out where the messaging or where the inaccurate information is coming from.”

The staffing situation

Gengler outlined the services Comprehensive Healthcare currently offers to Klickitat County, including mental health and substance abuse services. Currently the primary method of delivering those services is through telehealth, its usage having become increasingly common since the onset of the COVID-19 pandemic and its ensuing lockdowns.

He said at the nadir of Comprehensive Healthcare’s presence in the county, the organization employed seven Designated Crisis Responders (five of which also provided in-person outpatient services) for their facilities in Klickitat County, but currently only hire one for the role, as well as a part-time therapist in training and two substance use disorder counselors available, all of whom split their time between Goldendale and White Salmon.

To broaden the availability of services available to Klickitat County residents, Comprehensive Healthcare also provides telehealth services through DCRs in Walla Walla.

Still, Comprehensive Healthcare has seen positions unfilled for well over three years, Gengler said, noting that the organization’s main obstacle in the way of fully staffing its facilities is the ability to recruit talent and hire people willing to work in the area, “like most other healthcare entities.”

“We’d love to be in person, but we just don’t have the staffing available,” he said.

Despite staffing challenges, Comprehensive Healthcare utilizes a full team of Designated Crisis Responders at the Walla Walla campus available to provide telehealth services, to which, in response to a questions posed by County Commissioner Dave Sauter, Gengler said that the Walla Walla campus was able to be fully staffed because it is in a more attractive location to new hires.

Gengler said that despite a full staffing situation in Walla Walla, the mental health needs are still outgrowing the level of services they provide there. “So if you’d put a one to 10 scale, and 10 is the most acute (in terms of staffing challenges), Klickitat would be a 10, while Walla Walla is probably a seven.”

Gengler noted Klickitat County does not receive as many requests for DCR services than in other locations (the organization also serves Yakima).

Over the past year, 201 requests from Klickitat County have been made, and response times have averaged 32 minutes, Gengler said; 76 requests were responded to by a DCR from Walla Walla, and 201 were responded to by a Klickitat DCR.

He credited the use of telehealth as a way of lowering response times, and noted that while Comprehensive is currently in a staffing slump, he always has noticed a rebound following such dips in staffing over his 34 years in the field.

A representative from Beacon Health Systems, which oversees Comprehensive Healthcare’s contracts with the state, noted during the meeting that Comprehensive Healthcare receives a flat sum monthly in state funding, regardless of the staffing availability. She said she could not share the dollar amount in state funding the organization receives, noting that the funding does not cover outpatient services outside of a crisis. Gengler noted that Beacon Health Systems was instrumental early on in the pandemic in their efforts to retain staff, as well as providing sign-on bonuses and other incentives.

Gengler said Comprehensive Healthcare struggles to compete in the job market because the organization is not a critical access hospital, unlike Skyline Hospital and Klickitat Valley Health, and therefore does not receive additional federal funding to enhance wages, but offers wages competitive and “even pay higher in this area versus other regions for community behavioral health agencies.”

How does a crisis response normally work?

Gengler outlined the typical process through which crisis services are delivered to patients as requested by law enforcement.

He said that typically the phone call comes into the crisis line, which is then routed to one of the DCRs to communicate with law enforcement. If the DCR is out in the community, more then likely they are going to the hospital because a law enforcement officer has brought somebody there for an evaluation, he said. The DCR then assesses whether the individual meets the criteria for involuntary detention, which at that point, the individual must be medically cleared to go to an inpatient unit, treatment facility, or psychiatric inpatient hospital.

A way forward

Dibble, in response to a question probing what the organization’s plan to fill position, said that the organization is raising salaries across the agency, as well, they just hired a new marketing position in order to “ramp up publicizing that.”

She noted that the county will continue to be a challenge in the future as people are less willing to move here.

Recently, the DCR hired to serve Klickitat County has been participating in a program, funded by Southwest Washington Accountable Communities of Health (SWACH), to perform ride-alongs with officers of the Bingen-White Salmon Police Department.

B-WS Police Chief Mike Hepner said the program, which he started last year, first began with ride-alongs with a behavioral health specialist.

“I’m all about that program, it works great. The nice thing about having a DCR is, if need be, she’s available to take the person into protective custody,” Hepner said, noting the organization is the only one of its kind in the county to offer DCR services.

Hepner said the goal of the program is to be proactive and respond before a person enters a mental health crisis.

“It’s more about being upstream, I want to say, and not catching the bodies as they fall out, as they come down the river. It’s addressing the problem before the crisis occurs,” he said.

Hepner noted that, sadly, the Bingen-White Salmon community has had five suicides this past year — “small town USA: That should not be happening. But it does, and it’s increasingly going up.”

His concern he brought to the representatives from Comprehensive Healthcare was the process that occurs when there is no bed available. In the state of Washington, DCRs cannot detain an individual if no hospital bed is open. He said that nine times out of ten, the individual signs a safety plan which releases them from care.

“Ultimately, the state needs to step up and do more for the community’s mental health,” he said.

County Director of Public Health Erinn Quinn mentioned that her office frequently receives questions from the community inquiring about mental health services, which are extremely limited at the office. Quinn said the department has taken up a perinatal mental health program in the last year, which has prompted public health staff to seek support from Comprehensive Healthcare but have not heard a response. She said she was looking to Comprehensive Healthcare to provide clearer information about how community members can access their services.

Dibble responded, saying that it’s possible the department’s questions have not been elevated to the proper channels. She said in response to concerns about access, that the process to be seen by a counselor can be cumbersome for a new patient.

“Behavioral health is very different from physical health. You can’t just go in and be seen for an ailment … There are specific requirements that must be collected.”

Dibble added that calling ahead of time is beneficial because a call center can help walk individuals through the process.

Jenna Barkhimer, Skyline emergency physician assistant, said that burnout was common among Comprehensive’s DCR staff because of their workload and structure of the job. She also noted that there is not crossover in coverage between Skamania and Klickitat counties because the two agencies contract out to different groups.

“So we are trying to bridge people and, I am not a mental health prescriber, but I’m having to try and bridge people until they can get to see somebody, where the you guys are the only game in town when it comes to our Medicaid patients, and most of the private-pay people, our patients can’t afford,” she said.

Washington Gorge Action Programs Executive Director Leslie Naramore told the representatives that there is a negative community perception of Comprehensive Healthcare, based on the many interactions she has had especially with individuals on Medicaid.

“Some of the things that we’ve started doing, once we’ve heard that there’s community perceptions that need fixed is, we’ve started meeting with the police chiefs, law enforcement (and) the hospitals and trying to talk through and sort through  what are the issues and how can we help,” Dibble said. “It is going to be a challenge until we get fully staffed. And when we’re all competing for the same staff, trying to serve the same clients, it is going to be a challenge.”

“To me, it’s about to regain trust, it’s consistency. I can talk all I want in this meeting about my grandkids and why it’s a big deal, that we provide the services and how embarrassed I am. But it’s all about put up or shut up, and what we can deliver, and what we can’t deliver,” Gengler said. “If we’re fully staffed, it’s going to be: Are we delivering the services that we said we’re going to deliver? Are they meeting the needs of the community in the types of services that are needed? Do we have the therapists who are well trained in evidence-based practices, and I can show you through data and outcome measures, what we’re what we’re delivering— I think that’s the only way to regain trust.”