Editor’s note: This is the first story in a series on the weak spots in Maine’s care for children with mental health challenges.

The Maine Department of Health and Human Services last month quietly overhauled a statewide emergency service that’s supposed to be available around the clock for children and adults experiencing suicidal thoughts, severe bouts of depression, crippling anxiety or any other mental health crisis.

The first realignment of Maine’s network of mental health crisis services in two decades came without public engagement and with limited preparation. The department says it doesn’t expect to save money as a result of the move, but a change in how it’s paying for the service has some of the private agencies that provide it unsure they can afford to continue providing it long-term.

The state’s corps of emergency mental health workers are there for anyone who calls the statewide crisis hotline looking for help. Hospital emergency rooms, county jails and police departments that need help de-escalating dangerous mental health-related situations are also frequent hotline callers. So are family members concerned about loved ones’ safety.

Since the 1990s, the state has contracted with the same handful of agencies to deliver crisis services in specific regions around the state. A call to the statewide crisis hotline (888-568-1112) rang at the offices of the nearest regional crisis services provider, where mental health workers would offer support over the phone and, if needed, go out to meet the caller face to face to make sure they were safe and develop a plan for follow-up treatment.

The agencies also operated short-term residential crisis units where people could stay for a few days to remain safe and stabilize. There were 17 units statewide in 2016, according to DHHS: 11 for adults and six for children.

“A good day at work means that no one dies,” said Michael Mitchell, CEO of Crisis and Counseling Centers in Augusta, the state-designated crisis services provider for Kennebec and Somerset counties. “If it’s working well, then nobody knows we’re here.”

The overhaul that took effect April 1 meant the following:

— The state switched crisis service providers in western Maine and in parts of southern Maine.

— Calls to the crisis hotline (there were 173,000 in 2014, according to DHHS) started going to a single call center run by The Opportunity Alliance in South Portland. If the situation requires face-to-face follow-up with a mental health worker, call center employees alert the appropriate local crisis services provider. Maine DHHS “wanted as many calls resolved on the phone as possible,” said Joe Everett, The Opportunity Alliance’s chief program officer.

— And instead of being able to count on a set amount of revenue from the state each month, the regional agencies that send out mental health workers to meet with people in danger of harming themselves and others are now paid only when they deliver a service and bill for it. That’s akin to paying a local fire department only when it responds to a fire, although firefighters need to be available at all times.

“It’s definitely less predictable. If it’s a very slow month, you’re still running a 24-7 program with staffing and no money coming in,” said Stephanie LeBlanc, executive director of Oxford County Mental Health Services. “With the change to the fee-for-service model, there’s no support for running the program.”

Already, LeBlanc’s organization has reduced staffing. For the majority of the 24-hour day, it has one staffer on duty for all of Oxford County; during peak hours, it has two. That’s a change from traditionally having one staffer on duty in Rumford and another in South Paris at most times, LeBlanc said.

“There’s definitely delays in response times at this point,” LeBlanc said.

Mitchell said he’s concerned that one of the first statewide systems in the country for helping people with mental health problems in their communities “is being watered down,” and without a clear rationale from DHHS.

“I still don’t know what it is that we’re trying to solve,” Mitchell said.

With Maine’s suicide rate on a long-term rise, and with suicide the second most common cause of death among 15- to 34-year-olds, he said, “to do anything but to invest in the system flies in the face of reason.”

‘A billable cost’

Crisis workers meet with people who ask for help wherever they are — at home, at school, in a hospital emergency room — and try to help them out so they stay safe.

In the Oxford County town of Rumford, which the Androscoggin River bisects, “more often than I’d like to admit, we are responding to someone on the bridge with the police,” said LeBlanc.

Consulting with a mental health clinician, crisis workers develop a plan for next steps: connecting people with their existing care providers or setting them up with new ones; finding a bed for a few days at a residential crisis unit; or locating a psychiatric bed at a local hospital. Crisis workers often make the next steps happen and follow up.

Though callers access the services through the same number, crisis services for mental health situations are distinct from crisis services for adults with intellectual disabilities.

For every person the crisis workers help, it typically takes about six phone calls to learn enough about the situation and coordinate next steps, said Mitchell, the CEO of Crisis and Counseling Centers.

With the state’s fee-for-service reimbursement, “all those things have to be turned into a billable cost,” he said. “In the real world, turning that stuff into real, billable time that fits Medicaid rules and passes the straight-face test has been a challenge.”

When the people they’re helping have health insurance, crisis service agencies bill MaineCare, the state’s Medicaid program, or their private insurance. They then can bill from a pool of state money to cover services for uninsured clients.

Mitchell said it’s too early to predict the full impact of switching exclusively to a fee-for-service model, but Crisis and Counseling Centers did see its payment from the state drop off in the first month of the new setup. If that continues, Mitchell said, Crisis and Counseling might have to shrink its crisis staff.

“It’s about making sure that there is adequate coverage and investment in a system that is complex and requires a complex skill set and a workforce that is unique,” Mitchell said. “You have to be available for demand, and we’re only being reimbursed for actual utilization.”

That’s also posed a challenge for some of Crisis and Counseling’s other services. The agency has a long-standing ride-along program with the Waterville Police Department, in which a mental health worker joins police during night shifts. It more recently began a ride-along program with police in Augusta.

But the ride-alongs don’t neatly fit into fee-for-service reimbursement, Mitchell said.

“At this point, we have no way to cover that program,” he said. “I’ve got no feedback from the state [in response to questions about how to pay for it]. I’ve asked twice. Right now, we’re eating it.”

The same goes for the agency’s outreach to local organizations to offer crisis counseling following school or workplace tragedies.

“I’m definitely not going to go to a public school and say, ‘Here’s a bill for $5,000 for our time,’” Mitchell said. “These are the things that we haven’t been able to get any answers to, and won’t fit very easily into this fee-for-service [payment].”

From Skowhegan to statewide

Crisis services in Maine have their roots in the early 1980s, when Crisis and Counseling Centers and the state collaborated on a pilot project in Skowhegan to determine whether making crisis workers available in the community allowed more people with psychiatric problems to receive treatment locally and stay in their homes, rather than end up in hospital emergency rooms or psychiatric beds.

State officials were so pleased with the results they expanded the service to three regions of the state and hired state employees to staff it, said Lynn Duby, who led Crisis and Counseling Centers from 1983 to 1996 and again from 2008 to 2014.

By the late 1990s, following pressure both to expand the service and to contract it out, Duby said, the state had a full network of organizations across the state answering crisis calls; meeting in person with clients in crisis to provide preliminary counseling and determine next steps; and running short-term residential crisis units.

“They wanted to insert more consistency across the state in the type of programming that people received so, as a consumer, you wouldn’t receive a radically different program in York County than you would receive in Bangor,” said Duby, who directed the state Office of Substance Abuse and later the Department of Behavioral and Developmental Services under Gov. Angus King from the mid-1990s to the early 2000s.

So the crisis organizations formed the Maine Crisis Network, agreed on a uniform set of policies and protocols, and developed a single training program for all crisis workers, she said. In setting up their statewide crisis networks after Maine, Duby said, a number of states requested the Maine crisis worker training curriculum.

While the state originally paid the providers a flat amount from state funds, it started relying on private insurance and Medicaid — for which the federal government assumes about two-thirds of costs — over time to cover some of the costs as state officials tried to plug budget holes, Duby said.

Until April 1, crisis services providers billed MaineCare or private insurance when the person they were helping had coverage. But they could count on the state to cover up to an agreed-upon amount to cover the costs they couldn’t bill for, including for services they provided to people without health insurance.

“Essentially, it was a break-even mechanism,” said Dale Hamilton, executive director of Community Health and Counseling Services in Bangor, which provides crisis services in Penobscot and Piscataquis counties. “Now, it’s volume. If the amount of need is lower in any given period of time, obviously, then, we’re not able to bill for any of that time, so there’s no mechanism for compensation.”

The state now dips into its available pool of state funds only to pay for billable services the crisis service organizations provide to uninsured clients, removing the payment that helps the organizations break even.

‘In limbo since 2015’

The changes that took effect earlier this spring have been in the works since 2015.

That’s when the state issued requests for proposals to provide crisis services throughout the state and to run the call center. It had settled on its chosen bidders by the end of the year, service providers said. But following legal challenges of some of the awards, DHHS had to reissue a request for bids to cover three of the department’s eight service regions. It issued that request last summer and chose the vendors in December 2017.

For crisis service agencies in much of the state, more than two years passed between learning the state had chosen them to work in the new crisis system and the switch to that new system. During that time, there was no indication of when the switch would occur, and DHHS offered little information about the finer points of the new setup.

“Over that period of time, we didn’t receive any information about what the contracts would look like. Obviously knowing that there would be a single phone provider, there were a lot of details to work out,” said Hamilton, the director of Community Health and Counseling Services. “There really was no ability for us to start any kind of planning during that three-year time frame.”

And with the switch looming, but no knowledge about when it would happen, a number of crisis workers left their positions because of the uncertainty, said Mitchell of Crisis and Counseling Centers.

“We were kind of in limbo since 2015,” he said. “That had an impact on workforce. All of us have struggled to fill vacancies, which has impacted access and wait times.”

While The Opportunity Alliance received word in January that it would take over call-answering duties in April, the regional crisis service providers didn’t receive that confirmation until the last week of March, Mitchell said. That was the first time those agencies were able to review their new contracts with the state and the terms they would have to satisfy.

With days before the switch, Mitchell said, “our choice was either to sign, or we would be out of the crisis business.”

Hospital emergency rooms noticed some “hiccups” with the hotline in the new system’s first week, said Jeffrey Austin, vice president of government affairs and communications for the Maine Hospital Association. The system has since improved, he said.

A number of law enforcement agencies contacted by the BDN weren’t even aware of the switch and didn’t notice a difference in their access to crisis services. Chief Deputy Christopher Wainwright of the Oxford County Sheriff’s Office said his deputies have only needed to change the phone number they call.

“When we need it, you can’t put a price tag on it,” he said of crisis services. “When they’re doing the job, they’re worth every cent.”

Regional crisis service providers say they’ve generally had few problems receiving requests for help. But their employees have encountered long wait times when calling the call center back to deliver updates on the situations they’ve been assigned.

“You can imagine the higher volume when one provider is taking all the calls,” said Hamilton. “Time’s going to get squeezed somewhere.”

No budget impact

A DHHS spokeswoman said the department reformulated the crisis system “in order to bring more accountability and reliability to the Crisis Services system, which had a history of functioning inconsistently across the state.

“For example, there were different service expectations and outcomes depending upon where in the state a person intersected the legacy system,” the spokeswoman, Emily Spencer, wrote in an email.

She didn’t provide examples of inconsistent service.

She said of the switch to exclusively fee-for-service payments for face-to-face crisis workers, “By definition, this model will bring a greater quality of care to the uninsured. The fee-for-service model also represents a tool in the movement toward a ‘Money Follows The Person’ system, where the consumer comes first and often has greater discretion.”

Spencer said the change will have no impact on DHHS’ overall crisis services spending.

While leading Crisis and Counseling Centers and coordinating the Maine Crisis Network between 2008 and 2014, Duby said she heard state officials occasionally suggest a single call center to answer all crisis calls and dispatch face-to-face crisis workers. But she never heard a rationale for the change nor any concerns about the quality of services.

Duby had reason to be concerned about centralizing the call-taking for the entire state in one location.

“If you’re going to do an evaluation in one agency and then transmit that information to another agency before that agency can send someone and provide the service, you have opportunity for the information to change, for the information to be garbled,” Duby said. “It’s like that old ‘telephone’ game.

“If you screw up in crisis services, someone could die,” she said.

Everett of The Opportunity Alliance said the organization’s 30 or so call specialists are familiarizing themselves with the resources available in each region. The organization is drawing on its experience running the call center for 211 Maine, a statewide hotline with information on accessing services such as addiction treatment and heating assistance, Everett said.

The state’s explanation that it sought more consistency and accountability doesn’t add up for Duby, who worked with crisis service providers and state officials through the years to bring consistent practices and training to one of the country’s first statewide crisis systems.

“This is one of those situations where all the cards are in the hand of the funder, so they license you; they tell you how many staff you need to have, what the qualifications of the staff are, the facility qualifications,” she said. “So, I’m not clear where the inconsistency would come from because the department is the one who defines what you do.”

Maine Focus is a journalism and community engagement initiative at the Bangor Daily News. Questions? Write to mainefocus@bangordailynews.com. If you are experiencing a mental health crisis, call the crisis hotline at 888-568-1112.

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