As an Anchorage Fire Department paramedic for the last eight years, Michael Riley routinely helped people in crisis. He knew how to treat physical wounds. He could recognize and respond to a heart attack or slow bleeding from a gunshot wound.
But when called to assist people in mental distress, Riley wondered whether he was really helping.
His training taught him simply to bring them to an emergency room. And if someone threatened harm or self-harm, protocol meant restraining the patient, something he thought may have caused greater trauma and exacerbated symptoms.
The system stressed limited resources at Anchorage hospitals, and didn’t necessarily improve outcomes for patients, Riley said.
“For me it was a frustration on those calls because I knew that wasn’t the right thing for every situation,” he said.
This summer, the fire department debuted the Mobile Crisis Team, a program that pairs a paramedic with a mental health clinician to respond specifically to behavioral health crisis calls.
The program is the first step in a larger plan to redesign the way Alaska handles mental health crises to avoid unnecessary hospital visits and connect people to more appropriate resources. Alaska Mental Health Trust leaders said the new approach is based in part on a system developed in Arizona, the “Crisis Now” system, and may one day also include a stabilization center for short-term evaluation and treatment for anyone.
But the future of the newly formed Mobile Crisis Team is unclear. Mayor Dave Bronson proposed cutting the funding for the program in half and moving remaining funds to the Anchorage Police Department. It’s not clear how the program would operate under police direction.
The Mobile Crisis Team
On a Friday afternoon this fall, Riley and clinician Jennifer Pierce, a former Anchorage police officer, knocked on Gary Davis’ door. The team sees Davis frequently and sometimes reaches out during times when he’s not in crisis to check in.
For Davis, their visit was a pleasant surprise.
He smiled as he pulled on his shoes and chatted with Pierce, eager to tell her about his friends and his plans to wax the floor in his apartment and teasing her about not being able to play hacky-sack.
For a moment, he yells out in pain and Pierce comforts him. Davis has a traumatic brain injury that contributes to chronic pain and he also experiences depression, Pierce said.
They used to respond to him weekly, but the calls have become less frequent lately, Riley said. Now, when he’s in crisis, he knows to ask for the Mobile Crisis Team, Pierce said.
Riley has known Davis, a heavy user of fire department services, for about three years, he said.
The difference in Davis is obvious, Riley said. Davis used to go to the emergency room roughly 70 times in a year but hasn’t been there in several months, Riley said. He has an apartment, he’s socializing and going outside more, and his physical mobility has drastically improved. The team walked around the block with him for 15 minutes on a pleasant fall day, and Davis left them with a joke, as he often does, before they parted ways.
Success looks different for each call. Sometimes it’s immediate — like when Pierce is able to calm someone experiencing a panic attack for the first time and discuss with them skills for how to respond to it in the future. Or when they can help transport a patient experiencing hallucinations or delusions to a hospital safely without having to restrain them.
But sometimes success requires a longer wait, seeing a person do better over time, as with Davis.
After each call, the team follows up with patients in 24 to 48 hours to see how they’re doing. Many people experiencing mental health problems have a difficult time advocating for themselves and often struggle to follow through with connecting to community resources, Riley said.
“Maybe they had reservations about calling or maybe they’re having a hard time acknowledging that they’re in crisis ...,” he said. “We were finding that a lot of individuals were just getting lost in the system.”
The Mobile Crisis Team is currently composed of two clinicians and three firefighter paramedics who provide the services in teams of two from 10 a.m. to 8 p.m. daily. There’s hope that the program could expand hours in the future.
The program is funded by roughly $1.5 million generated from the alcohol tax approved by Anchorage voters last year. Riley said they are also working to gain Medicaid certification to help fund the program through billing.
Data from the team‘s first few weeks showed 80% of patients stayed in the community and were connected to either previous providers or given a referral to services. The team’s response meant other fire teams were able to respond to other calls and resulted in significantly fewer hospitalizations. Riley said the team is generally responding to 30 to 40 calls weekly now.
The calls were initially dispatched through the fire department’s dispatch center, but Riley said the team began working to train police dispatchers about their work in October.
Riley said he expects the collaboration with both dispatch centers to increase the team’s call volume.
Anchorage has few resources for mental health emergencies, Riley said. There are seven designated psychiatric beds at Providence Alaska Medical Center, but other hospitals do not have designated beds, he said. When Providence beds are full, as they often are, patients are diverted to other hospitals.
The diversion means more time spent by first responders trying to find care for the patient, costing police officers time that could be spent focusing on public safety or crime investigation and leaving paramedics out of service to respond to other calls for help.
For the patient, it means waiting longer for appropriate help.
Often, when these calls involve police, they can end with incarceration.
De-escalation training is not standard for first responders in Alaska nor in the rest of the country, Riley said. And first responders have few tools to deal with the complexities of mental illness and trauma. The Mobile Crisis Team has provided a short training to the fire department about how to de-escalate situations, and some first responders have asked for additional training.
Some Anchorage police undergo Crisis Intervention Training, and the department also has a co-responder program that pairs a mental health clinician who can respond with an officer to calls where mental illness may be involved.
A bigger picture
Several years ago, the Alaska Mental Health Trust joined discussions with community leaders about how to reshape mental health care in the state.
The Crisis Now system was introduced in Alaska after consultation with RI International, a company that specializes in behavioral health response. The vision for Alaska is based on a model in Arizona that has now been adopted throughout the country.
The system relies on three basic components: a crisis call center, mobile crisis teams and stabilization centers.
The call center provides immediate assistance from a trained clinician for anyone experiencing a mental health crisis. Many of the crises are able to be resolved over the phone, but about one in 10 callers may need additional care from an in-person team, the trust estimates.
In that situation, a mobile crisis team responds to evaluate or calm the situation and provide support.
The Mental Health Trust hopes that patients who need additional assistance can eventually be transported to a 23-hour crisis stabilization center. The centers offer mental health and substance use care to anyone — accepting all walk-ins, ambulance, fire and police dropoffs. The centers avoid unnecessary hospitalizations and allow patients to receive specialized mental health or substance use care immediately.
A case study in Maricopa County, which includes Phoenix, found a decrease in spending on inpatient hospitalization of $260 million a year and a reduction in psychiatric boarding time of 45 years annually. And because first responders were able to drop off a person experiencing crisis with no wait time, the stabilization centers freed up the equivalent of 37 full-time law enforcement officials to focus on public safety each year.
A 2019 recommendation compiled by RI International found that Anchorage police officers typically spend two to three hours on each behavioral health call. Some calls have taken up to 10 hours. Calls with no arrest or behavioral health issues can take 15 to 30 minutes, the report said.
Anchorage, Fairbanks and the Mat-Su were recognized as areas where the Crisis Now model would be most effective. Anchorage’s Mobile Crisis Team marked a first step here, Riley said, and a similar team is beginning in Fairbanks this fall.
Funds from the trust were approved for Providence and the Southcentral Foundation to study and plan for stabilization centers, said Katie Baldwin-Johnson, a senior program officer with the trust. The study is expected to last a year with the ultimate goal of seeing those services in Anchorage within a couple of years, she said.
An uncertain future
When Mayor Dave Bronson announced the proposed city budget for 2022, neither Riley nor Pierce was aware that drastic changes were included for the Mobile Crisis Team.
The proposed budget cuts roughly $1.5 million allotted to the program from the alcohol tax. About half of those funds are proposed to go toward the Anchorage Police Department.
Chief Ken McCoy said during a news conference that the program will be moving to the police department to partner officers with mental health clinicians or social workers.
“Many of you know I’m a big proponent of mental health response, and having that capability in our community is vital,” McCoy said. “I want to thank (Anchorage Fire Department) Chief Schrage and his team for standing up the program and getting those services out in the community. After some meetings and discussions amongst our team and staff, we feel we can realign those services within the police department underneath our Mobile Intervention Team and expand on services that we are already providing.
“And that would be social workers, mental health clinicians, partnered with our police officers who are trained in critical incident and getting them out there in teams.”
The police department has not provided any additional information about what the program would look like if it were moved and declined to discuss it in an interview. A spokeswoman for the police said by email that the details “have not been finalized or sorted out between the Municipality. APD doesn’t have any new information to share.”
Assistant Fire Chief Alex Boyd said the proposed changes came as a surprise to both the fire and police departments. At this point, it’s unclear what will happen with the program. The mayor’s office hasn’t provided additional information about what the plans are for the mobile crisis team.
“To be completely frank, we’re just not sure what the answer is going to be. … We won’t know until the budget process goes full length,” Boyd said.
He said the fire department remains committed to the work that the Mobile Crisis Team has been doing and will help however necessary, whether it means continuing the work in their department or helping the program transition elsewhere.
The Anchorage Assembly has not yet voted on the mayor’s proposed budget.
There to help
In early October, as Riley drove the team’s Chevy Suburban down a busy street in Anchorage’s Fairview neighborhood, Pierce spotted a woman crying alongside the road.
Pierce walked up to the woman, crouched to meet her at eye level as she talked with her. Within a few minutes, they start walking toward Sullivan Arena, where the woman is staying.
Pierce said she focuses on building rapport quickly and making sure patients know she’s there to help.
As a former police officer, Pierce said, she is familiar with crisis response from other perspectives. She made a career change after she was seriously injured during a car crash and decided to go back to school to earn a master’s degree in clinical psychology. She’s still taking classes, now working toward a doctorate.
Like Riley, Pierce said when she was an officer, she also felt ill-equipped to handle mental health crises.
In those instances, the work she does now is more effective, she said. Pierce can tell that the work the team does now makes a difference, even when it’s as small as holding someone’s hand or answering the phone when they call.
“It’s so surprising how much just connecting and supporting with someone ... can really help someone feel better about themselves and help them feel connected to the community as well,” she said.
As Pierce walked the woman back to Sullivan Arena that fall afternoon, the woman’s tears faded.
As they stopped at the doors to the shelter, the woman wrapped her arms around Pierce.
“She really needed a hug,” Pierce said as she settled back into the Suburban.
Correction: A previous version of this story incorrectly stated Katie Baldwin-Johnson’s last name.