Tuesday, September 01 | Thought Leadership, Human Services, Care Coordination

Connecting Communities to Care

By Netsmart

Often times a major aspect in successful care delivery is serving people where they are located. Barriers to care such as transportation, scheduling or more recently physical distancing measures can make it difficult for some individuals to seek in-office healthcare services. This is especially true for mental and behavioral health services.

In order to best serve complex populations, behavioral health organizations need to work to partner with community organizations to more efficiently facilitate care and meet individual needs. Partnering with community outlets such as schools, jails and law enforcement brings case management and crisis services directly to the consumer, which in turn improves access to care, reduces recidivism rates and leads to more individuals served. Virtual technology and mobile solutions are key in creating initiatives through community partners in order to enhance access to care.

WellStone understood the importance of being responsive to their community and addressing those needs in the complex populations they serve. The community mental health center is located in Alabama and serves more than 14,000 clients every year. During a recent OPEN MINDS and Netsmart webinar, Connecting Communities to Care, WellStone CEO, Jeremy Blair, shared several initiatives the organization is taking to close gaps and eliminate barriers to care within their community through technology and partnerships.

Stepping Up Initiative

It is shown that 40% of individuals with a serious mental illness have been incarcerated once in their lives. Often times these individuals are put in jail for non-violent, minor crimes or even bizarre behavior simply because it is the most viable option as opposed to hospitalization for law enforcement on the scene. When the individual is put in jail, it delays or eliminates proper treatment, increases risk of recidivism and increases costs and use of community resources.

In order to provide better care and avoid unnecessary incarceration, WellStone started to build case management into their program. Through the Stepping Up Initiative, they began hiring case management staff who would track individuals to ensure they were linking to appropriate mental health services once they were released from jail. Some WellStone clients who had been incarcerated didn’t have access to basic needs such as housing, food or medication. These social determinants of health (SDoH) can impact mental health as well as recidivism rates. The Stepping Up Initiative empowers case manages to help the individual obtain these necessities.

WellStone’s Stepping Up Initiative has saved a county more than $1.7 million in a two-and-a-half-year period. They currently manage a caseload of 84 people and achieve a recidivism rate of less than 6%. The initiative has spread to 15 counties across the state and has caught the eye of legislators due to success rates.

Crisis Intervention Training (CIT)

Knowing there was a more efficient and proactive way for law enforcement to assist people in a mental health crisis than resorting to arrest, WellStone began a CIT partnership with the Huntsville Police Department (HPD) in 2017. CIT educates law enforcement on how to properly approach and de-escalate a situation where someone is in a mental health crisis in order for them to receive proper care and avoid arrest.

HPD applied for a grant that helped them develop the CIT program, which eventually led to a specialized CIT unit. The model of training is law enforcement led and is now used at three Alabama law enforcement agencies where more than 50 officers have been trained. The officers go through initial training as well as additional training through WellStone. They shadow outreach teams and visit inpatient and crisis units in order for the officers to get a realistic sense of who the clients are and the common experiences they face.

Once the CIT officers arrive at the scene, they assess the situation and then contact a WellStone mental health professional to ensure the individual in need receives specialized assistance. However, a phone call isn’t always the most effective way of communication. WellStone wanted to leverage video calling for CIT officers to connect virtually with a behavioral professional while onsite. When Netsmart launched its Telehealth App, WellStone adopted the tool to enhance their virtual response model. Allowing the behavioral health professional to physically see the individual and the scene through the telehealth app paints a better picture, therefore giving more insight into what follow up care might be necessary.

Within the past six months, WellStone has brought together a group consisting of a specialized treatment team of law enforcement, treatment providers and first responders. Together they are looking at high utilizers of special services such as ambulances or non-urgent 911 calls. WellStone and the team are then assigning staff to work with those high user individuals. Often times its matter of lack of housing, food or other social determinants of health that are forcing these individuals to face emergency services. The group can work to not only assist people in need, but also save costs and reallocate necessary special services.

Virtual care in schools

Traditionally, counselors are embedded in schools to provide mental health services to students face to face. WellStone’s school-based program employs more than 50 therapists in four school systems. Having the counselor in the school eliminates a transportation barrier for the child or the need for a parent or guardian to take off work to bring their child to an appointment. This model makes mental health services accessible and feasible for many students.

When COVID hit, WellStone alongside many other providers had to adjust their care delivery models. Some of their more rural schools had already been leveraging remote care through the Netsmart virtual kiosk. For the providers who weren’t already using virtual care before COVID, an integrated telehealth solution was adopted so care could continue despite physical distancing.

WellStone continues to move forward with more interactive ways to best serve complex populations within their region. By partnering with community organizations and using virtual technology, behavioral health providers like WellStone can reach individuals where they are and better connect their communities to care.



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