Late at night, the only thing open in Appanoose County, Iowa was the Hy-Vee grocery store. Not much else, and certainly not a 24-hour facility where people with mental illness could go for help. For that matter, they didn’t even have that during daylight hours.
Instead, they would have to go to the hospital or jail, or on a long ride out of town with a deputy to find an open psychiatric bed somewhere, maybe as far away as South Dakota. There was nowhere else to go. In a rural county of roughly 12,000 people, it was hard to expect more.
“Nobody was getting any mental health care,” said Jackie Sharp, a clinical therapist and executive director of Centerville Community Betterment — Centerville is the Appanoose County seat. “We were spending all of this money transporting people four hours away to facilities, only to find out they were being discharged within 24 to 48 hours back to their home community without any treatment.”
But these people weren’t as far out of mind as it would seem. The results of the local hospital’s Community Health Needs Assessment — mandated by the Patient Protection and Affordable Care Act — revealed that Appanoose County residents prioritized what the county didn’t have — mental health care options. In the nearly four years since, therapists are available to emergency room doctors around the clock and five beds are available at a short-term crisis stabilization house in the middle of town, one that has become a model for the state.
“It was a big wakeup call for the county,” said Diane Buss, the central point coordinator for mental health in Appanoose County who started in that position soon after the needs assessment. “We knew there was a need but we couldn’t put our finger on it.”
But the signs were there. Four-month waits to see a psychiatrist who had to travel up from Kansas City once a month, for a week at a time. Days during which a sheriff’s deputy would have to accompany a patient who was sitting around all day waiting to be committed for treatment, then the 77 times deputies had to drive patients elsewhere for treatment in 2012 and 2013.
“We don’t have a lot of deputies in town, but one of them had to spend all day with a patient while they waited to be treated,” Sharp said. “Usually, they were just sitting around the emergency room, waiting. It meant a lot of overtime costs for the sheriff’s office.”
In that same two-year span, 144 out of 180 Appanoose County residents committed to inpatient facilities for mental health or substance abuse issues ended up not needing that level of care. It all totaled roughly $1.2 million per year, and that wasn’t even paying for top-of-the-line care that was appropriate for patients’ needs.
“Everyone thought like there wasn’t anything we could do, and the hospitals were frustrated for many years, law enforcement was frustrated for many years,” Sharp said. “We all complained about what we don’t have — we don’t have a psychiatrist, we don’t have this and we don’t have that and we don’t have these therapists, we had all these reasons why we weren’t going to be able to do anything in this rural county.”
The mounting costs and the needs assessment results prompted the formation of a mental health coalition, which included Buss, Sharp, Sheriff Gary Anderson, Ann Young of Mercy Medical Center-Centerville Medical Center — the local 25-bed hospital — and Dewey McConville, president of the South Central Iowa chapter of the National Alliance on Mental Illness. The goal: reduce the number of commitments by 80 percent — the proportion of patients who had been improperly committed.
Eighty percent was a little short of the 85 percent average proportion of commitments for mental health issues in rural counties statewide compared to the 15 percent Polk County — Des Moines — committed, according to a nonprofit that the coalition consulted. The rural-urban mismatch was striking to Buss and Sharp, who betted there was a way to cut down Appanoose’s emphasis on inpatient care.
“We went to Des Moines (and talked to mental health workers there) and they told us that the majority of the people that rural counties sent there could be treated in our community with our resources,” Sharp said. “They told us to design our program to what we have and what we can do.”
Helping the Helpers
The first step was getting trained mental health therapists in the emergency room to help doctors properly diagnose mental illnesses and direct patients to the right treatment. Sharp initially filled in, on-call 24 hours a day, until Buss recruited more therapists to help out. She invited every one she knew working in Appanoose County to lunch.
Four therapists are now available to perform on-call evaluations, find permanent supportive housing options and locate open inpatient facility beds if a patient’s diagnosis calls for it.
“Therapists work in their own little box,” Buss said. “You know (which patients) you work with but there wasn’t a community of therapists here. I got them together for lunch, I dangled the carrot, and I said ‘there’s money available…this is what we’re looking for.’”
Finding locally-based therapists was helpful not just logistically, but made the emergency room less chaotic when residents with mental illness came in.
“A lot of our emergency room doctors aren’t local and they don’t know the mental health community,” Buss said. “The therapists, on the other hand, really get to know the people, especially those with chronic illnesses, so they know their backgrounds and their issues. For a long time, there wasn’t much follow-up so people would just wind up back in the emergency room again. The therapists add a comprehensive level of care.”
Sharp said the community at large is recognizing the value in mental health treatment options.
“They know there were major gaps in treatment,” she said. “They’re going beyond just being afraid of ‘crazy people’ and they’re actually supporting actions to get help for people with mental health difficulties.”
Their 80 percent reduction goal? They blew right by it, some months cutting 90 percent from the pre-2014 average commitments. But that still left a remaining population that needed more.
Safe at Home
If a patient does need more than a hospital therapist or out-patient treatment provider can offer, there is now an option in Appanoose County.
In 2014, Centerville Community Betterment, a nonprofit social services agency, opened Oak Place, a five-bed crisis stabilization center inside a ranch house. A $50,000 grant from Appanoose County funded the starting costs until the South Central Behavioral Health Region — the state’s mental health funding mechanism for Appanoose, Davis, Wapello and Mahaska counties — stepped in to fully fund the house and pay for Sharp to work as the house’s therapist.
What wasn’t spent on rent went to furnishing the house and buying things visitors would need, including hygienic supplies. A subsequent $221,000 grant from Catholic Health Initiatives helped with funding before the region’s funding kicked in.
It became a safe place for people in the middle of mental health crises to stay for up to seven days, during which time they can be under the care of therapists and have help managing medication and figuring out their next step. Oak Place does not accept commitments, and all patients are free to leave.
“They write their own care plan, their own emergency plan before they’re discharged,” Sharp said. “We thought it might not work in the beginning, but we’ve found that if they have the ability to self-determine their outcomes and make decisions about the plan, they do a lot better and are a lot motivated than if they’re court ordered.”
The crisis-stabilization house model debuted in Appanoose County is now required in each of Iowa’s 15 behavioral health regions, and 11 others have opened so far.
Sharp has been proactive about paving the way for a smooth introduction into the neighborhood for Oak Place.
“We knew there would be some concerns, but keeping lines of communication open and letting the neighbors know you’re open to feedback helps build the neighborhood relationship.”
Oak Place is open to residents of the region’s three other counties. The coalition has added a four-bedroom transitional housing apartment in Davis County to which Oak Place residents can move.
“It’s a place people in a mental health crisis can go and get the help they need, any time of day,” Buss said. “It’s a long way from where we started, and we’re showing that being in a rural area doesn’t mean not having options.”
Sheriff Gary Anderson agreed that the new mental health options have eased the burden on his deputies.
“We get some (emergency) calls and all they need is someone to sit down with them and give them some of the services (we now offer) and not tie up the services they don’t need from an emergency committal,” he said.Hero 1