‘Where’s the workforce?’

Counseling services struggles finding crisis responders

NEWPORT – In a frustrating trend across the nation for both behavioral health providers and the people that need those services, Pend Oreille County Counseling Services (POCCS) has had to make the difficult decision to cut back its 24-hour designated crisis responder (DCR) hours, due to the limited availability of DCRs in the Pend Oreille County area. The changes took effect Feb. 1.

“Unfortunately, this is not a unique situation,” Pend Oreille County Counseling Services Director Annabelle Payne says. “This is something counties, especially rural ones, are struggling with throughout Washington and all over the country.”

DCRs evaluate individuals who are exhibiting signs of a behavioral health disorder, including acute mental disorder/substance use disorder and if those individuals might pose as a danger to self, others or the property of others or are gravely disabled, meaning unable to care for their basic needs of health and safety.

Currently, the crisis response hours at POCCS are 8 a.m. to 4:30 p.m., Monday-Sunday. For crisis services during daytime hours, call 509-447-5651 or 800-404-5151. For after hours, including weekends and holidays, people should call 877-266-1818.

According to Payne, in late 2020 POCCS was down to one DCR, who also carried a caseload during regular hours. At this point the POCCS Clinical Supervisor and Crisis Services Manager had to routinely be in the crisis after hours services rotation.

“Understandably, these committed staff were on a burnout track and we were at risk of losing all staff that were qualified to do the DCR work, thus no crisis response even during regular business hours,” Payne says. “Abbreviated crisis hours were implemented to at least maintain crisis services seven days week.”

POCCS contacted the state and regional Behavioral Health Administrative Services Organization (BHASO) in late 2020, stating that counseling services could not continue with the current funding and staffing model.

“Fortunately, the response was to provide additional funding to support new dedicated DCR positions,” Payne says. “Unfortunately, in the midst of our crisis program 'crisis', there is currently a national shortage of behavioral health providers, especially clinicians with a Masters degree, which is statutorily required to be a DCR.”

Washington state law requires that a person training to become a DCR must be a psychiatrist, psychologist or a physician assistant working with a supervising psychiatrist, psychiatric advanced registered nurse practitioner, or social worker. People who are licensed by the department as a mental health counselor or mental health counselor associate, or marriage and family therapist or marriage and family therapist associate also qualify. All applicants must have a Master's degree or further advanced degree in counseling or one of the social sciences from an accredited college or university and, “at least two years of experience in direct treatment of persons with mental illness or emotional disturbance, such experience gained under the direction of a mental health professional.”

It doesn’t stop there, though. DCR training, or “onboarding” includes learning all county and agency policy and procedures, as well as learning how to use the electronic medical record system. DCRs must also complete a state one-week "Boot Camp" training as well as other specific training modules provided within the counseling services department, before completing a DCR exam. They must also shadow other DCRs for in-field training observation and demonstrate understanding of how to perform an ITA (Involuntary Treatment Act), do bed searches and complete the various minutiae of reporting requirements. The entire process takes an average of three to six months, Payne says.

Payne estimates around six DCRs have left POCCS in the last two years, with two retiring, two receiving higher paying jobs in Spokane and another going into private practice. Starting annual salary for a new DCR is $64,200. Currently, there are two new DCR hires for POCCS that haven’t completed training yet and there is an opening for a third.

County tax doesn’t include behavioral crisis response

One point of confusion for county residents regarding DCRs could be the 1/10th of 1% sales and use tax passed by Pend Oreille County commissioners last September. County commissioners had been considering the tax for the last several years, which by state law does not require a public vote in order to be implemented. While the impression for some might be that funds generated from the tax go directly to POCCS, they don’t, Payne says. The tax was implemented to help alleviate financial and social issues put on the county’s law enforcement and justice system. People with behavioral/mental health disorders and substance abuse disorders often end up in jail because there are little options in the way of treatment and care, according to county officials.

With the tax, people pay one cent per $10 in non-essential purchases, which does not apply to grocery food. It raises the county sales tax from 7.6 percent to 7.7 percent, possibly generating about $100,000 a year starting in 2021. The tax is not just borne by Pend Oreille County residents, but also people traveling through the county spending money at local businesses.

However, there’s no guarantee that the majority of that money will go toward POCCS. The amount of funding increase to support the three new DCR positions comes from the state. Previously at $480,184, the crisis program is now funded at $568,717 for an increase of $88,533 annually.

The crisis program is a cost reimbursement funding model, meaning the contract allocates a maximum amount, but POCCS can only bill for actual costs expended. For example, until the third DCR position is hired, POCCS cannot legally draw down funds for the position.

“The 1/10th tax is about filling gaps, not supplanting a budget or other funds,” Payne says. “It’s about helping address where behavioral health intersects with criminal justice and does not address 24/7 crisis response.”

POCCS had 282 crisis referrals in the last 12 months, averaging about 23.5 crisis per month. Payne points out that the number of crisis referrals does not reflect the staffing time needed to work the crisis. This includes DCRs performing evaluations and doing the coordination work such as finding a bed in a designated mental health facility, securing transportation, completing the paperwork and other reporting requirements.

“For example, finding an inpatient bed could take hours and sometimes the effort is for naught, should no bed be available,” Payne says. “Furthermore, during the day, staff other than DCRs provide crisis supports like triage, coordination and crisis stabilization.”

Basically, the pool of qualified DCRs is low, making it hard for agencies like POCCS to hire and retain them. POCCS is currently budgeted at 27 employees, with five of those positions unfilled (not all are DCRs).

“The question is, where’s the workforce? Where are the people who can and want to do crisis response? Crisis services is very important and we’re trying to get that up again to where it should be,” Payne says. “You have to ensure that the base knowledge and skill set is there. It’s pretty intense work and sometimes people’s lives are on the line. You have to make sure people doing these evaluations are competent and care.”

Payne did not have an exact date for when 24/7 crisis response would resume, saying it depends on when POCCS can fill the third DCR position.