About once a week, Glacier County EMS (GCEMS) responds to a call of a person in a mental health crisis. During the fiscal year from July 1, 2017, to June 30, 2018, GCEMS responded to 153 behavioral health calls, which involved suicide attempts, general mental health, or ingestion of a substance and mental health, according to data provided by Amie Allison, EMS director.
While an exact percentage is difficult to ascertain because it is not uncommon for a call to have a mental health issue underlie the primary reason for the call, those 153 behavioral health calls made up about 11 percent of Glacier County EMS’s 1,365 calls from last year.
These calls are complex for EMS personnel but also essential to the mental health care for patients in crisis.
“We generally are called to a person with a mental illness during a critical time or crisis moment for 911 calls,” Allison explained.
Justin Grohs, the general manger of Great Falls Emergency Services, echoed Allison’s experience at his workplace.
Mental health calls are “definitely something that EMS is faced with and routinely handles,” said Grohs.
Allison’s experience in Glacier County is consistent trends around the country. Nationally, as many as 10 percent of all patients who present at emergency rooms had a psychiatric illness, according to a 2016 study published in the Western Journal of Emergency Medicine.
Those patients are transported to the emergency room, and perhaps transported to an out-of-area facility from there, released to home care to a friend or family member, or remain at the local hospitals for observation.
Allison likes to think of additional care, especially in inpatient facilities, as a way to “refill their toolbox. Sometimes those tools are just misplaced and it’s time to get some new ones or review how to use them properly,” she said.
Patients may be placed on medications or receive behavioral therapy at out-of-area inpatient facilities throughout the state, from Butte to Billings and from Kalispell to Great Falls.
“Where we travel to is dependent on the age of the patient, the concerns associated to the patient, and honestly, if there is a bed open,” Allison said.
Finding a facility with an open bed for the patient is a constant problem, she said.
If there is a bed, EMS is called upon to transport the patient to the facility. Before the patient leaves, Allison explained that the patient is informed in plenty of time for them to process the reality of being moved; a patient history is completed so EMS knows if the patient has a history of transport and how the patient has responded to transport; and a care plan is prepared to help keep the patient comfortable and everyone safe.
EMS sometimes gets to know patients very well on those transports, especially if patients are transported multiple times.
“We do have the opportunity to visit with new patients, and more so with patients that have been transported multiple times… We really get to know some of our patients,” she said.
Transportation to an inpatient facility is “for intervention” and “to resolve the threat and to again, give them tools for their tool box and have the ability to cope and exit into outpatient services,” Allison explained.
That move back to the community and to outpatient services is sometimes fraught too. Allison worries about issues surrounding continuity of care, especially when a patient is transported to multiple inpatient facilities over time and those facilities may or may not share information about that patient.
Ultimately, Allison believes, information about the patient’s treatment in inpatient facilities, in the ER, or with EMS “really needs to make it back to the primary care provider… If this information is at home base, we can focus on the prevention aspect. Those appointments can be monitored through a care coordinator assisting the individual to make appointments [for] mental health, primary care and any others that may be required.”
To that end, Glacier County EMS instituted Glacier County Integrated Mobile Health in 2017, in which EMS providers provide home visits to patients based upon their providers’ referrals. The goal of this and other programs is to reduce the number of hospital readmissions and visits to the ER for patients and to save money in the process, according to a January 2017 article in the Cut Bank Pioneer Press that introduced the program.
For patients with mental health needs, these visits allow EMS staff to review medications, make sure patients are taking the appropriate medications and at the appropriate dosages and work with providers and pharmacists to make sure the patients’ needs are met.
The program can also help patients with needs that are not directly medical. They may refer patients to the Montana Warm Line, a hotline where a person with mental illness can speak to a peer in recovery, or make sure they are aware of the National Suicide Prevention Hotline. EMS staff can also help patients secure meals, connect them with job placement or retraining, or provide education about nutrition or exercise.
Yet Glacier County’s high poverty rate – a 2016 report from Montana State University Extension found that the county’s poverty rate of 33.7 percent is about twice the state average – means that some patients do not have the economic resources even to get to a medical appointment or get medications.
“Maybe finding food is more important that worrying about their medications,” Allison said.
Making sure needs are met is crucial because patients who lack reliable food, a job or other outlets may escalate to a crisis, Allison said. And crises are what everyone wants to avoid.
“911 and emergency rooms are not where we want to see these individuals. We do not want them to be in crisis,” said Allison. “That’s why it really is important to see the collaboration to build the support network.”
EMS providers have gone through training to identify and interact with people in mental health crisis, and rigorous continued education requirements allow for more training in mental and behavioral health too.
“An ER provider or an EMS provider has to know a little bit about a lot of things… That is why it is important to see more specialty care for mental health services,” she continued.
Such specialty care may only be available in an inpatient setting far from the patient’s home, which is one reason why Allison would like to see an inpatient treatment facility on the Hi-Line someday.
It takes collaboration among many providers and agencies to help support mental health. Allison compares the collaboration to the support she and her family have received in raising her son, who has special needs. As a caregiver for her son, Allison says she has experienced the “roller coaster” of good days and bad, similar to the experience of family members of people with mental illness, who want to help and find solutions to help their loved ones.
“I always say it honestly takes a village to raise my son with special needs, and if it was not for this great community – my village – I could not have done it. As a village, we need to help patients and families of mental health [patients],” she said.
And as for the EMS providers themselves? Responding to high-stress calls means that EMTs and paramedics experience a high rate of PTSD in their field. A survey whose results were published in the October 2015 Journal of Emergency Medical Services found that about 6.6 percent of the surveyed EMS providers had attempted suicide, which is about 10 times more than in the general population.
Burnout is common among EMS providers, but Allison tries to look after the mental health of the providers at Glacier County EMS. Particularly traumatic calls, including deaths, may necessitate a critical stress debriefing team to come to debrief with the providers.
But Allison believes that this experience allows EMS providers to empathize with patients who are struggling with their mental health.
“This shows why we have compassion for care with individuals with mental health,” she said. “It hits our family and our village.”