By Whitney Bunts

The need for mental health services continues to gain national attention, as evidenced by the impending implementation of 988 (the National Mental Health Crisis and Suicide Prevention Hotline to be launched in July 2022) and a rare public advisory from the U.S. Surgeon General. In order to meet this urgent need, we must establish a continuum of crisis services that address the mental health provider workforce shortage. One notable model in Seattle, a mobile response program that does not use law enforcement officers, provides a blueprint for what is possible.

Around 2016, the Seattle Fire Department partnered with the city’s Office of Aging and Disability Services in the Department of Human Services to fill this gap and meet the needs of the most vulnerable populations in the city. The fire department hired social work experts, known as case managers, to work alongside specially trained firefighters as part of the Health One program. The program is designed to address the mental health needs of specific groups of people in the community: frequent 911 callers, people with a wide array of behavioral health issues (including substance use disorders), people aging in place, people with chronic illness, and those experiencing homelessness.

Firefighters who opt to join the Health One program receive intensive in-house training on mental health first aid, motivational interviewing, crisis intervention, housing-first philosophy, trauma-informed care, harm reduction, and safety. Additionally, the firefighters and caseworkers participate in a joint ride-along and Fire/EMS module. The program’s goal is to ensure that these teams can meet people where they are, focusing on the immediate needs of the individual and then providing appropriate mental health support. After someone reaches out for help, Health One teams usually engage over a couple of weeks to ensure the person is stable; they prioritize being a part of a continuity of care (gaining access to health records and being able to work directly with the client’s physicians and other care professionals).

Due to limited capacity, Health One is currently unable to receive direct calls from the public. As a result, the teams primarily respond to calls through 911 or other firefighters who directly request them in the field and conduct ongoing outreach in the community. Despite capacity challenges, the Seattle Fire Department uses Health One as an opportunity to collaborate and partner with other institutions and organizations in the community, including homeless shelters, local mobile response teams, sobering centers, and the University of Washington. The fire department uses these partnerships as a chance to deter individuals from entering jails and emergency departments. In most cases, Health One teams use SUVs, taxis, and vans to transport their clients to locations all over the city to ensure their needs are being met and receive the resources and support that they need.

In addition to capacity challenges, the Health One team has a data collection issue. Currently, the Seattle Fire Department doesn’t collect data on its impact in the community. With more resources, the fire department hopes to collect data to gauge Health One’s effectiveness—but as of now, testimonials point to success.

Jon Ehrenfeld, Mobile Integrated Health Program Manager at the Seattle Fire Department, also noted that the case managers make less than specialty firefighter counterparts—who earn their normal salaries while they serve on the Health One team. Although the case managers are technically employed by the Department of Human Services, the fire department reached an agreement to pay their salaries if they worked for the fire department full time. However, the fire department is using the pay scale and job classification for Medicare/Title XIX, which grossly underpays counselors, case managers, and social workers.  This issue raises questions about Health One workers’ long-term sustainability and retention. Will the social workers continue to work there knowing they are doing the same job as their firefighter counterparts but being paid less? Probably not, which is likely to reinforce the mental health provider shortage.

A lack of providers is not unique to Seattle, but a nationwide problem that we must address. Many advocates are proposing solutions, such as co-responder models, that they believe will address this workforce shortage and adequately staff the crisis continuum. However, law enforcement involved in co-responder models are dangerous and will result in more trauma than healing. Comparatively, firefighters and fire services are better situated to respond to the needs of the community without barriers and preconditions.

If we want to see innovative co-response models like Seattle’s scale to address a workforce shortage, we must pay our providers more by increasing the reimbursement rate for their services. We must hire community health workers and peer support specialists to fill the gaps of the workforce shortage and make their services reimbursable through Medicaid. Finally, states and localities must use grants and funds distributed to fire departments for crisis workers. As communities prepare for the 2022 implementation of the new nationwide 988 crisis line, they have an opportunity to change the face of safety and make mental health services equitable and accessible for everyone. However, 988’s success depends on response services that are police-free and adequately funded.