(gentle uplifting music) - Many individuals and families face immense challenges when accessing mental healthcare services, especially during a crisis.

Joining us today to explore the root causes of these issues and their solutions are Jonathan Porteus and Christie Gonzales of WellSpace Health.

Jonathan, help us understand what currently happens to someone if we or our loved one has a mental healthcare crisis and needs immediate crisis intervention and care?

- Yeah, typically people call 911 or engage emergency services.

Increasingly, there might be urgent cares around or people go to the emergency department.

And so it's kind of a kind of a crapshoot.

And we're very keenly interested in increasing the capacity for people- - What do you mean it's a crapshoot?

Give us a little bit of color on that.

- I mean, for me, as a psychologist, the ideal is someone in crisis, especially a mental health crisis, be received as soon as possible by mental health providers.

And the current system is set up to bring people to, like an acute care setting, for example, where technically someone may be safe, but they're not actually immediately assessed and greeted by people who are mental health professionals.

- So, Christie, I want to put us right in the middle of this type of situation.

I have a loved one.

They have a complete break.

And we, myself, whoever else is around, are not able to calm them down, and they are literally out of their own personal control, and we're not able to manage them.

And so we're in crisis too.

First thing that we're gonna do is, as Jonathan said, call 911.

But the challenge is, is that sometimes whatever that response is tends to escalate things, not bring them down.

Help us understand what's broken with the system and why things are set up the way they are.

- A lot of times when someone's in crisis, it's not themselves who's calling for help, it's their loved ones.

And you're right, 911, it feels like the most appropriate place to call.

And you're gonna get a response by either law enforcement or maybe emergency medical services, ambulance.

And really you only have two choices from that point.

We're looking at, is jail the next step or is the emergency room the next step?

And those are places where there is a disincentive for being.

No one wants to wait six hours in an emergency room.

No one wants to be booked into jail, when really what they need is help, they need assistance.

And so what can we do to put help and assistance in place rather than something maybe even punitive?

- But stay with me right here on this binary choice people have, of if they call 911, it's either law enforcement or the ER, which typically they'd be taken by like an ambulance or something like that.

One of the things that I know has distressed everyone who's ever seen it, is someone has a mental healthcare break, the cops are called, and they were called by the family member.

The person ends up getting harmed and sometimes in some situations killed.

How does that circumstance take place?

What's missing from the system that allows that type of response to be one that is, "Well, we did what we could"?

- Well, if I may, firstly, we have very highly trained, skilled law enforcement professionals in our communities.

What they don't have- - But you're not disagreeing that that has factually happened in the past.

- Correct.

I'm actually going there.

I want to go right into it.

They don't have in their holster a weapon to deal with mental health.

And it's almost unfair to expect a sworn officer to deal with a mental health crisis.

And in that instance where there's nothing predictable, where command presence likes to create control and predictability, someone in a mental health crisis is unpredictable.

And that creates tension, fear, that triggers implicit bias, implicit responses.

And we see a lot of negative consequences, including some sort of stereotypic responses based on racial characteristics.

And so we do have those problems, especially with people in a psychiatric crisis.

And in our discussions and partnership with law enforcement, this is the thing they're asking us to solve for.

They understand that.

We've never spoken to law enforcement who didn't say, "How do we address suicidality, mental health crisis in a way that meets the needs of someone who's suicidal or in a mental health crisis?"

- So if someone ends up, Christie, if someone ends up in either jail, let's take that one first, and the ER, what happens to them next, typically under a system that is not functioning as it should?

- The biggest outcome, of course, of being booked into jail is now I've got a record, now I've got a court date that I need to meet in the middle of my preexisting crisis.

We wanna avoid that.

We wanna make sure that we address the crisis head on and that we can u-turn that person in crisis as early as possible before there is a charge, before there's a court date, before we start having bench warrants involved.

No one should have a record simply because they need mental health help.

- Incidentally, give us a sense, Christie, of the scale, the need for appropriate mental health healthcare intervention within this community.

How often is it that we have these situations where people are presenting in crisis, and whether they get the care they need or not?

But I just wanna get a sense of the scale of the issue.

- When we look at the fact that a lot of the emergency room visits are happening 'cause of a psychiatric evaluation, we know there's a high need.

WellSpace Health operates the 988 Suicide and Crisis Lifeline here in Sacramento, and we get over 2,000 calls a month just from the Sacramento region of the 916 area code alone.

So when we think of people that are ending up in the emergency room, or we think of people that are voluntarily calling 988 for that help, we know that there are thousands of people every month reaching out for help.

- Jonathan, are people reaching out for help because of the fact that there's just been a kind of anomalous, like, event where they've had a breakdown of some sort or a break of some kind?

Or is it also a part of the fact that even for those of us who have access to mental health care coverage, that the system doesn't work, and that sometimes either care arrives too slowly or not at all, and so therefore what happens is these things build up and someone has a crisis?

- I love your phrase, access to mental health coverage.

I don't actually know what that is.

I mean, I think the thing we deal with most with people in crisis is that they don't know how to access their mental health coverage.

There is no access.

There's no kind of slide you go down into your mental health coverage.

And your mental health coverage is select, specific, siloed.

And so- - Tell us more about that.

- So, all of a sudden, someone who's, let's say they're experiencing psychosis, which is literally a lack of the ability to have a straight thought.

How are they gonna access their coverage, even if it's pretty clear?

So all of a sudden you're trying to access a coverage that you've never accessed.

Families are scrambling to find out what is our coverage, because suddenly there's a mental health crisis.

what's needed in that moment is that care transition, is that slide is that warm handed relationship into care, into the right level of care.

And what I find in those moments, 'cause I get quite a lot of calls in those moments, is that the psychologist in me makes the assessment.

But really the case manager that used to do case management in the late 1980s is really at work, is saying, "How do I get this person into the right care setting?"

That's where we've never had an appropriate system.

Even if we have islands of high-quality psychiatric or psychologic care, we've never had a way of combining them into a crisis continuum, a way of conveying people through that.

And so people, they don't fall through cracks.

They get pushed through cracks.

- So here's what I don't understand.

There has been a ton of visibility in the meat, in the popular press, in popular culture and in legislative action over the past, I'll say, two decades on improving mental health funding, mental health care access.

Give us a sense of the root causes of the reason that this system still does not serve us well, particularly when we need it most.

- We have come a long way with the science, with the practice.

We have programs that are like jewels, but we need to string the jewels into a necklace.

That's not happened.

- Hmm, that's interesting.

Christie, from your vantage point, how is it that you turn Jonathan's statement about having the case manager who can take someone in or connect them to the right part of the process to the need as it emerges in the community in real time?

I'm not sure that most of us understand where to go or what to do.

- And that's the problem, right?

When a crisis happens, one moment, everything is normal, and the next moment something really urgent is presenting itself.

And so in that moment, we need to make it as easy as possible for people in crises or especially their loved ones to get that help.

And part of that system is what SAMHSA calls air traffic control, so- - Hold on, what's SAMHSA?

- Thank you, SAMHSA is the Substance Abuse and Mental Health Services Administration.

It's the federal organization that really works with mental health and with substance use to say these are some of the best practices that a community can create.

And so when they're talking about air traffic control, the idea is just like at the airport.

You know, a plane doesn't take off in Sacramento and land magically in Denver.

They are actually followed by each air traffic tower as they fly along the country to make sure they were at the right altitude.

Are they in the right areas that they need to be to avoid those errors?

And it's the same thing can happen in a case management situation in cases of emergencies.

Instead of asking the person in crisis who might have disordered thinking or might be actively intoxicated or inebriated, to give them a pamphlet or a phone number and to say, "Call this number and maybe you can get an appointment Monday at 9:00 AM," that's ridiculous.

We need to create a system that is an automatic conveyor belt through this air traffic control system where, when they are in crisis, they are automatically moved from one step to the next step so that the person in crisis or their loved one, who might not be familiar with navigating these systems, is not the one trying to string together these jewels, as Jonathan says.

There is a very clear pathway laid out for them.

And so through case management and through a really well-coordinated crisis system, we can achieve this air traffic control.

- All that sounds great, but that's not what we've got today, correct?

- It is not in place.

We have jewels, we have islands, but there are the gaps that exist.

- So, okay.

So I want you two to empower me, okay?

Let's say that later on this afternoon, I have a situation where a dear friend of mine has a break.

I get a phone call.

Can you come help, okay?

I am in real time next to this person.

What do I do, Jonathan?

- You call 988.

- Okay.

Tell us what 988 is.

- 988 is the Suicide and Mental Health Crisis Lifeline.

It's a national lifeline 24/7, three digits, 988.

Used to be 1-800-273-8255.

988's easier to remember, and that- - So, hold on, don't lose your point.

But, so do not call 911 first then?

- If you think you're in immediate danger or if the person's in immediate danger, go ahead, call 911.

'Cause the 988 response currently may not be as adequate as we want it to be 'cause we're starting to string the jewels.

But 988 is the place to start because they will give you resources.

We currently start dispatching.

And so slowly over time, we've started building a dispatch for mental health crisis in our region.

The best practice model says three things.

It says you need someone to call, you need someone to respond, and you need a place to go.

Okay, so we have 988 as someone to call.

Someone to respond would be the care coordination and air traffic control from 988 to mobile crisis teams, folks who are going out into the community to take the issue into their hands and from you, 'cause you're not trained for that.

And then we need a place to go.

And we need destinations that are not acute, not medical facilities or jails.

These are crisis-receiving destinations.

You see all this discussion about Prop 1 and all these amazing changes going on.

That's all part of the system.

- Hold on.

We're gonna get back to this.

But you mentioned something called Prop 1.

What exactly is Prop 1, and what does this have to do with any?

- Prop 1 is the sort of big legislative action that just happened in the last election where the Mental Health Services Act is being kind of re-engineered a little bit into the Behavioral Health Services Act.

It's more inclusive, and there's a huge amount of investment coming in from the state as part of the governor's initiative to build the capacity in every community to receive and treat behavioral health issues, behavioral health conditions and crisis.

And so increasingly, we're building out the right places to go when there's somewhere to go with someone in crisis.

We're even working on alternative destination laws.

Could an ambulance bring someone to a crisis site?

Currently, if an ambulance picks someone's up, there's only one place they can go, and that's the hospital.

- Really?

- Yeah.

There's no other place.

So if you want someone to go to a crisis-receiving site, like the one we built, often the crew of the rig will say, "Hey, can you send a case manager out?

Pick this person up."

They don't actually need an acute care setting.

Law enforcement will often drop people off 24/7 with us, 'cause they know that really what they need is a place to be evaluated, a place to manage the crisis and to kind of figure out next steps.

- So I've called 988.

I've gotten connected to the resources associated with that.

Is there currently this mobile triage resource that's going to come out to where I and this individual are so that they can get the help that they need or get taken to where they need help?

I mean, is it realistic at this moment that that capacity exists?

- Christie, if you could help me with this.

I believe that at this point in Sacramento County, we do have one team that technically is running 24/7.

And I wonder if you can describe the coverage and what our hope is, Christie.

- A couple of the local Sacramento-based police departments do have some mobile response.

That's a co-law enforcement and behavioral health provider response.

And then in Sacramento County there is a purely behavioral health response where it is a mental health provider and a peer with lived experience who's providing, so that's without that law enforcement essence.

That does operate 24 hours a day.

But there are times in those 24 hours a day, seven days a week where it's just one team.

So that means just one person in crisis at a time would be able to be helped.

And that's here in Sacramento County specifically.

It varies county by county.

So each community gets a really different response.

And that's why when we say, when we create, or thinking of creating the ideal crisis response system, we need to think regionally.

We need to think about the Greater Sacramento area where we're talking about West Sac, and we're talking about Roseville.

Because we know that sometimes these artificial lines of county lines, that's not how community members see themselves.

They see themselves as part of the Greater Sacramento community.

- So given the fact that there is one of these mobile units right now, and you're getting 2,000 calls a month on the crisis line, there's a big delta between available resources and need.

Jonathan, you spoke about this Proposition 1 and some of the things that it is going to, theoretically, bring.

How do you expect that Proposition 1 is going to change on the ground, say, in the next five years how people have access and coordination to better mental healthcare services, particularly in crises?

- Yeah, I think Proposition 1 is, one, paying for facilities.

It's how to develop the facilities.

We have a large crisis communication center coming up in South Sacramento and our new campus.

And that will help with not just receiving the 988 calls, but also the dispatch, which we currently do to this one team and to a couple of groups that just do their own transportation case management.

A piece of the bridge is to help EMS have an alternative destination, is to allow rigs, ambulances to go to other places other than an acute care hospital and emergency department.

Another piece of it is to empower law enforcement.

In our crisis-receiving site for behavioral health, which we started three years ago, our first client was law enforcement.

Every single drop off for at least a year was law enforcement.

And that whole issue of the dynamic between an officer and a person in crisis is very different if they're simply bringing someone to a behavioral health crisis center and dropping them off a crisis-receiving site.

Three-minute drop off, you don't have to hours and hours in a hospital waiting for the chain of custody to be handed to the hospital.

It's a simple drop off, it's a simple, "I'm worried about you, I'm actually just gonna drive you somewhere and drop you off."

There's none of that other kind of stuff that I described earlier on with command presence.

And so we can empower law enforcement, EMS, build capacity in the community, build mobile crisis, and build that at least that first step from crisis into the right place.

- And Scott, I'd like to jump in and talk a little bit about that demand for need versus the need for that mobile unit.

So when I say that the Sacramento area gets about 2,000 calls a month for 988 crisis, it's important to remember that 96% of those calls are resolved on the phone.

Not every phone call requires a mobile response.

When you think of this ideal system, if you think of the somewhere to call is the base of a pyramid, and then the mobile response is the middle of the pyramid, and then only the top few of that pyramid will actually need that safe place to be received.

Because sometimes all that's needed is that listening ear, connection to resources, understanding reasons to live, in some cases, if it is a suicidal caller.

That phone call saves lives 96% of the time.

We're only talking about those few folks that need to be escalated to that next level of care.

- Hmm.

- Yeah.

And we have the ability in our 988 continuum when you call to sort of stay on the line, to be sort of managed from, let's say, a lethality assessment into more of a crisis support, into a wayfinding and even em empowering family members if they're with them.

So we do resolve a lot of that.

And I should even say that the crisis receiving, once people are brought, like we've had about 10,000 drop-offs at our crisis receiving site in the last three years.

- 10,000?

- Yeah.

- That's a massive, massive number.

- It is, and there are a number of people who are coming repeatedly.

Just so you know, law enforcement or an ambulance would've taken someone to hospital or jail.

We do an assessment to see if someone does actually need an acute care setting, 'cause we're a health center.

4% of the people who've come to us end up in an ambulance going to the emergency department.

- That's it.

- 4%.

96% of the folks being dropped off stay with us and we work with them, resolve their crisis, transition them to another level of care.

- It sounds like, based on what you just described, that we, as a society, are wasting a lot of money by not calibrating the response to the need.

How did we end up in a system like this that, where it seems so obvious, based on what you both are saying, we've got this mismatch?

- We do have fragmentation across insurance companies, providers, different for-profit, non-profit, the Medicaid Medi-Cal population versus the commercially-insured population.

We have created opportunities for confusion, and combinations of permutations of healthcare that are so incredibly complicated you need to get a PhD in those.

And so we have created blockages.

And the goal here is to bring it all together, and make sure that if we're looking through the eyes of a person in crisis, all they see is help, hope, and the movement through a dignified continuum.

- And I think we will leave it there.

Thank you both and good luck on your work and supporting all of those.

- Thank you.

- All right.

And that's our show.

Thanks to our guests and thanks to you for watching "Studio Sacramento."

I'm Scott Syphax.

See you next time right here on KVIE.

(gentle uplifting music) All episodes of "Studio Sacramento," along with other KVIE programs, are available to watch online at kvie.org/video.