Iowa mental health regions expand services
Gazette - 2/17/2020
Feb. 17--When a family was mourning the death of their son, Foundation 2 mobile crisis services was called to help them through their grief.
Foundation 2, based in Linn County, is dispatched to various mental health crisis situations, from people who are thinking about suicide to parents who can't motivate their children to get out of bed to go to school.
Iowa's relatively new mental health regions have paved the way for mental health providers such as Foundation 2 mobile crisis services to reach beyond their county borders and into rural communities where resources are few and far between. But there have been some growing pains.
County supervisors are learning how to work together to decide how regional dollars will be spent. At the same time, the state has yet to provide money for the mandated services.
In the case of Foundation 2, the organization met the Linn County family's immediate needs first, donating food and covering the cost of some expenses. Later, Foundation 2 connected them with grief groups.
"This family had virtually no resources, the parents were very distressed. What we were trying to do is both stay out of their way and figure out how to help them," said Drew Martel, Foundation 2 director of crisis services.
Since Iowa has been divided into mental health regions, Foundation 2 has expanded out of Linn County and now serves six Eastern Iowa counties and the Quad Cities, and have trained eight other mobile crisis services across the state.
Regionalizing "has expanded mobile crisis to rural communities, and has allowed them to have access to services that they wouldn't have the funding or infrastructure to support individually," Martel said.
'Kicking and screaming'
The creation of mental health and disability services regions was an effort to build a network of mental health providers in collaboration with law enforcement, local hospitals, schools and mobile crisis services to reach all Iowans.
"The goal is to push the response as close to the individual as possible," said Bob Lincoln, chief executive officer of the 22-county County Social Services Region in Northern Iowa. "We have an opportunity to equalize and expand services."
The County Social Services Region brought five counties together as a pilot program in 2009. Today counties join to form regions through 28E Agreements, a plan among governmental agencies to provide a shared service, and designate a county supervisor to sit on the regional mental health board.
The County Social Services Region is starting discussions about how to support mobile crisis services. Lincoln said Foundation 2 has done a "fantastic job" and with the East Central Region, which Linn County is a part of, "paved the way" early for mobile crisis services.
Before counties regionalized, they provided mental health services on an individual county basis.
"Most of us went into regionalization kicking and screaming," recalled Shane Walter, chief executive of the Sioux Rivers Region in western Iowa, who has served as CEO since 2014 and previously was a mental health coordinator in Sioux County. "We were all pretty happy being individual counties, doing things our own way and having that control."
Since full regionalization in July 2014, the 99 counties have formed themselves into 14 mental health regions. State guidelines require each region to be three or more contiguous counties, have a hospital with in-patient psychiatric care and a community mental health center.
There were some contingencies. Polk County, for example, met all the requirements on its own and was able to be a stand-alone region.
Funding is achieved by each county meeting the per capita levy set by the region. That figure is determined by the regional governing board multiplying the amount of dollars set by the number of residents in each county.
Walter said there has been real success across the state in improving mental health systems. Counties together have access to funds and resources they didn't individually, he said.
However, not all counties were satisfied with the practices of their initial regions.
Some counties have traded in one region for another over the years.
Woodbury County, for example, swapped the Sioux Rivers Region for Rolling Hills Community Services Region in July.
This year, the Sioux Rivers Region is welcoming O'Brien and Dickinson counties from the Northwest Iowa Care Connections region, taking the region from three counties to five.
The Northwest Iowa Care Connections region is taking on Kossuth, Winnebago and Worth counties from the County Social Services region this year as well. This will cut off Emmet from the County Social Services region, possibly forcing them into Northwest Iowa Care Connection because of the state's contiguous law.
Muscatine County is hoping to trade in the Eastern Iowa Mental Health and Disability Services Region for Southeast Iowa Link. Approval is pending.
At the source of many of these disputes is money and differences in priority.
While the moves aren't all contentious, Walter said in the Sioux Rivers Region, Woodbury County, the biggest county in the region at the time, left over disagreements over how taxpayers money should be spent.
Urban counties often pay more to the region, and rural counties express concern they are paying for services being delivered to the urban counties.
Regionalization was an "arranged marriage," said Linn County Supervisor Ben Rogers, who has been on the East Central Region board since 2014.
"We didn't really know each other ... . We had to figure out how we were going to operate as a blend of urban and rural counties. The needs of both populations are very different," Rogers said.
The nine counties in the East Central Region have remained united since 2014, with no counties leaving or new counties asking to join.
Rogers said as a board member, being a part of a region is thinking about how money spent will serve the entire region and not just Linn County taxpayers. Linn County, a "resource-rich area," purposely has reduced some services within their own region to expand them to more rural communities, Rogers said.
Southwest Iowa success
Counties seeking to switch regions is a part of the "still developing" mental health system, said Suzanne Watson, Southwest Iowa region CEO.
The Southwest Iowa Mental Health and Disability Services region has had requests from other counties to join with it, but ultimately decided against them.
"We felt like we had really gelled as a region," Watson said. "It takes a lot of trust. Having providers that play well together, board of supervisors who play really well together, letting down some of our guard we have with creating (county) borders."
That region has worked together to equalize mental health services across their nine counties.
In fiscal year 2019, its mobile crisis team operated by Heartland Family Service responded to 376 calls, including face-to-face interactions and telehealth consultations. Calls originated from individuals needing assistance, mental health assessments in emergency rooms, law enforcement requests, pre-committal screenings and court orders.
Continuity in board leadership is a challenge for mental health regions.
Some counties choose to rotate annually which supervisor sits on the regional governance board. Other supervisors are not re-elected and a newly elected supervisor takes their place.
Rogers said its taken him years to understand how the region funds the complex mental health system.
"New members are drinking from a fire hose," Linn County Supervisor Rogers said. "There's no easy mental health and disabilities 101. When you have turnover, it can be very difficult, if not virtually impossible, to get those new supervisors up to speed because it is such a complicated system to navigate."
Walter said a change in leadership contributed to Woodbury County's exit from the Sioux Rivers Region last year. Woodbury County elected a new board of supervisors, and the relationship built with the region essentially started over, he said.
"A whole new philosophy came in," Walter said. "There were some differences in opinion over how things had always been done."
Lincoln said finding unity in the County Social Services region took some restructuring in 2016 in an initiative they called a Pivot.
While the County Social Services region is the largest geographically, they are only the third largest in terms of population, with around 460,000 people.
In 2017, it was spending more than $20 million to provide services to 22 counties. The Pivot restructured the region to form four quadrants, creating stronger care coordination teams who are specialists in understanding services available in their corner of the region.
In fiscal year 2019, the County Social Services region spending dropped to $13.5 million.
"Two years into the implantation of the Pivot has had profound results," Lincoln said. "We've significantly reduced our expenditures. We want to make sure our taxpayers aren't paying twice for the same service."
Large expenditures and sustainable funding can be a roadblock for regions wanting to expand services.
Walter of Sioux County said the Iowa Legislature "keeps piling on," mandating more requirements without tying funding to it.
In 2018, Gov. Kim Reynolds signed a law that mandated the addition of at least six regional access centers to provide short-term care to individuals experiencing mental health or substance-abuse crisis. At the time, there was no direction from the state on long-term funding and reimbursements for substance-use services versus mental health services.
"To their credit, it appears they're working on that this legislative session," Walter said.
Reynolds proposed a portion of a one-cent tax increase help pay for services in the mental health regions during her Condition of the State address Jan. 14.
The proposed 1-cent tax increase would reduce the mental health region's per capita levy from a maximum of $47.28 to $12.50.
House File 2151 introduced in the Legislature earlier this month would eliminate the requirement that mandates counties in a region to touch each other, which "would effectively gut the regional system," Walter said. He is not expecting it to get much traction.
Equity in voting
When the East Central Region hesitated to approve operational funding for access centers, Rogers countered that, as the largest county in the region -- contributing $7 million annually -- it should get a larger vote.
"I think the discussion was wanting greater equity," Rogers said. "I'm still a believer in one county, one vote. That requires collaboration and a nurturing of trust."
Lincoln said the County Social Services region also made a conscious decision to not have weighted votes.
"We wrestled with it when the Legislature allowed it ... . There's always struggles with larger counties having more influence in the collaboration. Every county has a vote. This creates a real partnership," Lincoln said.
Get connected to resources
Are you or someone you know struggling with mental health? Get connected to services through the Iowa Helpline, go to iowahelpline.org to call, text or chat online.
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